Clinical characteristics of upper cervical spine injuries in children: a retrospective case series.

OBJECTIVE: Pediatric cervical spine injuries (CSI) can be devastating, and children < 8 years are particularly at risk for upper CSI given unique anatomical differences. Diagnosis of these injuries can be delayed due to variable clinical presentations and a paucity of existing literature. The authors aimed to characterize the spectrum of pediatric upper CSI. METHODS: This was a retrospective, single-center case series of trauma patients aged < 16 years who were assessed at a level I pediatric trauma center and diagnosed with upper CSI between 2000 and 2020. Patients were included if they had evidence of bony or ligamentous injury from the occiput to C2 on imaging or autopsy. Data were obtained from manual chart review and analyzed using descriptive statistics. RESULTS: In total, 502 patients were screened and 202 met inclusion criteria. Of these, 31 (15%) had atlanto-occipital (AO) joint distractions, 10 (5%) had atlanto-axial (AA) joint distractions, 31 (15%) had fractures of C1-2, and 130 (64%) had ligamentous injury without joint distraction. Of the patients with AO injury, 15 patients had complete dislocation. They presented as hemodynamically unstable with signs of herniation and 14 died (93%). In contrast, 16 had incomplete dislocation (subluxation). They usually had stable presentations and survived with good outcomes. Of the patients with AA injury, 2 had complete dislocation, presented with arrest and signs of herniation, and died. In contrast, 8 patients with subluxation mostly presented as clinically stable and all survived with little residual disability. The most common fractures of C1 were linear fractures of the lateral masses and of the anterior and posterior arches. The most common fractures of C2 were synchondrosis, hangman, and odontoid fractures. Overall, these patients had excellent outcomes. Ligamentous injuries frequently accompanied other brain or spine injuries. When these injuries were isolated, patients recovered well. CONCLUSIONS: Among upper CSI, AO and AA joint injuries emerged as particularly severe with high mortality rates. Both could be divided into complete dislocations or incomplete subluxations, with clear clinical differences and the former presenting with much more severe injuries. Lateral cervical spine radiography should be considered during resuscitation of unstable trauma patients to assess for these CSI subtypes. Fractures and ligamentous injuries were clinically heterogeneous, with presentations and outcomes depending on severity and associated injuries.

Clinical Practice Guideline Recommendations in Pediatric Mild Traumatic Brain Injury: A Systematic Review.

STUDY OBJECTIVE: Our primary objectives were to identify clinical practice guideline recommendations for children with acute mild traumatic brain injury (mTBI) presenting to an emergency department (ED), appraise their overall quality, and synthesize the quality of evidence and the strength of included recommendations. METHODS: We searched MEDLINE, EMBASE, Cochrane Central, Web of Science, and medical association websites from January 2012 to May 2023 for clinical practice guidelines with at least 1 recommendation targeting pediatric mTBI populations presenting to the ED within 48 hours of injury for any diagnostic or therapeutic intervention in the acute phase of care (ED and inhospital). Pairs of reviewers independently assessed overall clinical practice guideline quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. The quality of evidence on recommendations was synthesized using a matrix based on the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework. RESULTS: We included 11 clinical practice guidelines, of which 6 (55%) were rated high quality. These included 101 recommendations, of which 34 (34%) were based on moderate- to high-quality evidence, covering initial assessment, initial diagnostic imaging, monitoring/observation, therapeutic interventions, discharge advice, follow-up, and patient and family support. We did not identify any evidence-based recommendations in high-quality clinical practice guidelines for repeat imaging, neurosurgical consultation, or hospital admission. Lack of strategies and tools to aid implementation and editorial independence were the most common methodological weaknesses. CONCLUSIONS: We identified 34 recommendations based on moderate- to high-quality evidence that may be considered for implementation in clinical settings. Our review highlights important areas for future research. This review also underlines the importance of providing strategies to facilitate the implementation of clinical practice guideline recommendations for pediatric mTBI.

Pediatric vs Adult or Mixed Trauma Centers in Children Admitted to Hospitals Following Trauma: A Systematic Review and Meta-Analysis.

Importance: Adult trauma centers (ATCs) have been shown to decrease injury mortality and morbidity in major trauma, but a synthesis of evidence for pediatric trauma centers (PTCs) is lacking. Objective: To assess the effectiveness of PTCs compared with ATCs, combined trauma centers (CTCs), or nondesignated hospitals in reducing mortality and morbidity among children admitted to hospitals following trauma. Data Sources: MEDLINE, Embase, and Web of Science through March 2023. Study Selection: Studies comparing PTCs with ATCs, CTCs, or nondesignated hospitals for pediatric trauma populations (aged ≤19 years). Data Extraction and Synthesis: This systematic review and meta-analysis was performed following the Preferred Reporting Items for Systematic Review and Meta-analysis and Meta-analysis of Observational Studies in Epidemiology guidelines. Pairs of reviewers independently extracted data and evaluated risk of bias using the Risk of Bias in Nonrandomized Studies of Interventions tool. A meta-analysis was conducted if more than 2 studies evaluated the same intervention-comparator-outcome and controlled minimally for age and injury severity. Subgroup analyses were planned for age, injury type and severity, trauma center designation level and verification body, country, and year of conduct. Grading of Recommendations Assessment, Development, and Evaluation (GRADE) was used to assess certainty of evidence. Main Outcome(s) and Measure(s): Primary outcomes were mortality, complications, functional status, discharge destination, and quality of life. Secondary outcomes were resource use and processes of care, including computed tomography (CT) and operative management of blunt solid organ injury (SOI). Results: A total of 56 studies with 286 051 participants were included overall, and 34 were included in the meta-analysis. When compared with ATCs, PTCs were associated with a 41% lower risk of mortality (OR, 0.59; 95% CI, 0.46-0.76), a 52% lower risk of CT use (OR, 0.48; 95% CI, 0.26-0.89) and a 64% lower risk of operative management for blunt SOI (OR, 0.36; 95% CI, 0.23-0.57). The OR for complications was 0.80 (95% CI, 0.41-1.56). There was no association for mortality for older children (OR, 0.71; 95% CI, 0.47-1.06), and the association was closer to the null when PTCs were compared with CTCs (OR, 0.73; 95% CI, 0.53-0.99). Results remained similar for other subgroup analyses. GRADE certainty of evidence was very low for all outcomes. Conclusions and Relevance: In this systematic review and meta-analysis, results suggested that PTCs were associated with lower odds of mortality, CT use, and operative management for SOI than ATCs for children admitted to hospitals following trauma, but certainty of evidence was very low. Future studies should strive to address selection and confounding biases.

Clinical Practice Guideline Recommendations in Pediatric Orthopaedic Injury: A Systematic Review.

BACKGROUND: Lack of adherence to recommendations on pediatric orthopaedic injury care may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aimed to identify CPGs for pediatric orthopaedic injury care, appraise their quality, and synthesize the quality of evidence and the strength of associated recommendations. METHODS: We searched Medline, Embase, Cochrane CENTRAL, Web of Science and websites of clinical organizations. CPGs including at least one recommendation targeting pediatric orthopaedic injury populations on any diagnostic or therapeutic intervention developed in the last 15 years were eligible. Pairs of reviewers independently extracted data and evaluated CPG quality using the Appraisal of Guidelines Research and Evaluation (AGREE) II tool. We synthesized recommendations from high-quality CPGs using a recommendations matrix based on the GRADE Evidence-to-Decision framework. RESULTS: We included 13 eligible CPGs, of which 7 were rated high quality. Lack of stakeholder involvement and applicability (i.e., implementation strategies) were identified as weaknesses. We extracted 53 recommendations of which 19 were based on moderate or high-quality evidence. CONCLUSIONS: We provide a synthesis of recommendations from high-quality CPGs that can be used by clinicians to guide treatment decisions. Future CPGs should aim to use a partnership approach with all key stakeholders and provide strategies to facilitate implementation. This study also highlights the need for more rigorous research on pediatric orthopaedic trauma. LEVEL OF EVIDENCE: Level II-therapeutic study.

Pediatric Moderate and Severe Traumatic Brain Injury: A Systematic Review of Clinical Practice Guideline Recommendations.

Traumatic brain injury (TBI) is the leading cause of death and disability in children. Many clinical practice guidelines (CPGs) have addressed pediatric TBI in the last decade but significant variability in the use of these guidelines persists. Here, we systematically review CPGs recommendations for pediatric moderate-to-severe TBI, evaluate the quality of CPGs, synthesize the quality of evidence and strength of included recommendations, and identify knowledge gaps. A systematic search was conducted in MEDLINE®, Embase, Cochrane CENTRAL, Web of Science, and Web sites of organizations publishing recommendations on pediatric injury care. We included CPGs developed in high-income countries from January 2012 to May 2023, with at least one recommendation targeting pediatric (≤ 19 years old) moderate-to-severe TBI populations. The quality of included clinical practice guidelines was assessed using the AGREE II tool. We synthesized evidence on recommendations using a matrix based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. We identified 15 CPGs of which 9 were rated moderate to high quality using AGREE II. We identified 90 recommendations, of which 40 (45%) were evidence based. Eleven of these were based on moderate to high quality evidence and were graded as moderate or strong by at least one guideline. These included transfer, imaging, intracranial pressure control, and discharge advice. We identified gaps in evidence-based recommendations for red blood cell transfusion, plasma and platelet transfusion, thromboprophylaxis, surgical antimicrobial prophylaxis, early diagnosis of hypopituitarism, and mental health mangement. Many up-to-date CPGs are available, but there is a paucity of evidence to support recommendations, highlighting the urgent need for robust clinical research in this vulnerable population. Our results may be used by clinicians to identify recommendations based on the highest level of evidence, by healthcare administrators to inform guideline implementation in clinical settings, by researchers to identify areas where robust evidence is needed, and by guideline writing groups to inform the updating of existing guidelines or the development of new ones.

Sport-related concussion and bodychecking in children and youth: Evaluation, management, and policy implications.

Concussions are a common injury both within and outside sport and recreational settings, and they remain a serious concern for children and youth. Any young person suspected of sustaining a concussion should be medically evaluated as soon as possible, and when the injury occurs during sport, the individual must be removed from play immediately to avoid secondary injury. A brief initial period of physical and cognitive rest is followed by supervised, stepwise return-to-learn and return-to-play protocols. All individuals involved in child and youth sports and recreation must be able to recognize risk for, and signs and symptoms of, concussion. They must also ensure that any participant suspected of sustaining a concussion is properly evaluated and managed by qualified medical personnel. Evolving data and literature have strengthened both our pathophysiological understanding of concussion and guidance for clinical management, especially related to acute care, persistent symptoms, and prevention. This statement also re-examines the relationship between bodychecking in hockey and injury rates, and advocates for a change in policy in youth hockey.

Clinical practice guideline recommendations for pediatric solid organ injury care: A Systematic Review.

BACKGROUND: Observed variations in the management of pediatric solid organ injuries (SOIs) may be due to difficulty in finding and integrating recommendations from multiple clinical practice guidelines (CPGs) with heterogeneous methodological approaches. We aimed to systematically review CPG recommendations for pediatric SOIs. METHODS: We conducted a systematic review of CPGs including at least one recommendation targeting pediatric SOI populations, using Medical Analysis and Retrieval System Online, Excerpta Medica dataBASE, Web of Science, and websites of clinical organizations. Pairs of reviewers independently assessed eligibility, extracted data, and evaluated the quality of CPGs using the Appraisal of Guidelines Research and Evaluation II tool. We synthesized recommendations from moderate to high-quality CPGs using a recommendations matrix based on Grades of Recommendation, Assessment, Development, and Evaluation criteria. RESULTS: We identified eight CPGs, including three rated moderate or high quality. Methodological weaknesses included lack of stakeholder involvement beyond surgeons, consideration of applicability (e.g., implementation tools), and clarity around the definition of pediatric populations. Five of the 15 recommendations from moderate to high-quality CPGs were based on moderate quality evidence or were rated as strong; these reflected nonoperative management and angioembolization for renal injuries and required length of stay for liver and spleen injuries. CONCLUSION: We identified 15 recommendations on pediatric SOI management from 3 moderate or high-quality CPGs, but only one third were based on at least moderate-quality evidence or were rated as strong. Our results prompt the following recommendations for future CPG development or updates: (1) include all types of clinicians involved in the care of pediatric SOIs and patient and family representatives in the process, (2) develop clear definitions of the target population, and (3) provide advice and tools to promote implementation. Results also underline the urgent need for more rigorous research to support strong evidence-based recommendations in this population. LEVEL OF EVIDENCE: Systematic Review/Meta-analysis; Level III.

Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care: A Systematic Review.

OBJECTIVE: To systematically review clinical practice guidelines (CPGs) for pediatric multisystem trauma, appraise their quality, synthesize the strength of recommendations and quality of evidence, and identify knowledge gaps. BACKGROUND: Traumatic injuries are the leading cause of death and disability in children, who require a specific approach to injury care. Difficulties integrating CPG recommendations may cause observed practice and outcome variation in pediatric trauma care. METHODS: We conducted a systematic review using Medline, Embase, Cochrane Library, Web of Science, ClinicalTrials, and grey literature, from January 2007 to November 2022. We included CPGs targeting pediatric multisystem trauma with recommendations on any acute care diagnostic or therapeutic interventions. Pairs of reviewers independently screened articles, extracted data, and evaluated the quality of CPGs using "Appraisal of Guidelines, Research, and Evaluation II." RESULTS: We reviewed 19 CPGs, and 11 were considered high quality. Lack of stakeholder engagement and implementation strategies were weaknesses in guideline development. We extracted 64 recommendations: 6 (9%) on trauma readiness and patient transfer, 24 (38%) on resuscitation, 22 (34%) on diagnostic imaging, 3 (5%) on pain management, 6 (9%) on ongoing inpatient care, and 3 (5%) on patient and family support. Forty-two (66%) recommendations were strong or moderate, but only 5 (8%) were based on high-quality evidence. We did not identify recommendations on trauma survey assessment, spinal motion restriction, inpatient rehabilitation, mental health management, or discharge planning. CONCLUSIONS: We identified 5 recommendations for pediatric multisystem trauma with high-quality evidence. Organizations could improve CPGs by engaging all relevant stakeholders and considering barriers to implementation. There is a need for robust pediatric trauma research, to support recommendations.

Evaluation of activation criteria in paediatric multi-trauma.

Objective: To explore the optimal set of trauma activation criteria predicting paediatric patients' need for acute care following multi-trauma, with particular attention to Glasgow Coma Scale (GCS) cut-off value. Methods: A retrospective cohort study of paediatric multi-trauma patients aged 0 to 16 years, performed at a Level 1 paediatric trauma centre. Trauma activation criteria and GCS levels were examined with respect to patients' need for acute care, defined as: direct to operating room disposition, intensive care unit admission, need for acute interventions in the trauma room, or in-hospital death. Results: We enrolled 436 patients (median age 8.0 years). The following predicted need for acute care: GCS <14 (adjusted odds ratio [aOR] 23.0, 95% confidence interval [CI]: 11.5 to 45.9, P < 0.001), hemodynamic instability: (aOR 3.7, 95% CI: 1.2-8.1, P = 0.01), open pneumothorax/flail chest (aOR: 20.0, 95% CI: 4.0 to 98.7, P < 0.001), spinal cord injury (aOR 15.4, 95% CI; 2.4 to 97.1, P = 0.003), blood transfusion at the referring hospital (aOR: 7.7, 95% CI: 1.3 to 44.2, P = 0.02) and GSW to the chest, abdomen, neck, or proximal extremities (aOR 11.0, 95% CI; 1.7 to 70.8, P = 0.01). Using these activation criteria would have decreased over- triage by 10.7%, from 49.1% to 37.2% and under-triage by 1.3%, from 4.7% to 3.5%, in our cohort of patients. Conclusions: Using GCS<14, hemodynamic instability, open pneumothorax/flail chest, spinal cord injury, blood transfusion at the referring hospital, and GSW to the chest, abdomen, neck of proximal extremities, as T1 activation criteria could decrease over- and under-triage rates. Prospective studies are needed to validate the optimal set of activation criteria in paediatric patients.

Evolving threat of pediatric ingestions: a discussion of cannabis and button batteries and their implications for children.

PURPOSE OF REVIEW: Pediatric button battery and cannabis ingestions are rising in incidence and have the potential for significant harm. This review will focus on the clinical presentation and complications of these two common inadvertent ingestions in children, as well as recent regulatory efforts and advocacy opportunities. RECENT FINDINGS: The rising incidence of cannabis toxicity in children has corresponded with its legalization across several countries in the last decade. Inadvertent pediatric cannabis intoxication is most commonly due to the ingestion of edible forms discovered by children in their own home. The clinical presentation can be nonspecific, therefore clinicians should have a low threshold for including it on their differential diagnosis. Button battery ingestions are also increasing in incidence. While many children are asymptomatic at presentation, button battery ingestions can quickly cause esophageal injury and lead to several serious and potentially life-threatening complications. Prompt recognition and removal of esophageal button batteries is essential for reducing harm. SUMMARY: Cannabis and button battery ingestions are important for physicians who take care of children to recognize and manage appropriately. Given their rising incidence, there are many opportunities for policy improvements and advocacy efforts to make a difference in preventing these ingestions altogether.

Safely reducing abdominal/pelvic computed tomography imaging in pediatric trauma: a quality improvement initiative.

OBJECTIVE: Intra-abdominal injury occurs in less than 15% of pediatric trauma activations but can be life-threatening. Computed tomography (CT) imaging is commonly ordered in pediatric trauma, even when intra-abdominal injury risk is low. We aimed to reduce abdominal/pelvic CT rates in children at very low risk for intra-abdominal injury requiring trauma activation at our pediatric trauma centre. METHODS: We implemented a quality improvement initiative using the Model for Improvement in children 0-15.99 years of age who activated a trauma response and were evaluated for intra-abdominal injury. Interventions included clinical decision support, institutional education, and individual audit and feedback. Our primary outcome was abdominal/pelvic CT rate in patients at very low risk for intra-abdominal injury. Balancing measures included CT scans ordered within 24 h of emergency department (ED) assessment and return to ED or hospitalization within 72 h for missed intra-abdominal injury. Statistical process control was used to evaluate rates over time. RESULTS: The baseline period (April 1, 2016 - November 30, 2017) included 359 trauma patients with a CT rate of 26.8% (95% CI 20.5-33.8%) in those at low risk for intra-abdominal injury. The intervention period (Dec 1, 2017-Dec 31, 2019) included 445 patients with a CT rate in low-risk patients of 6.8% (95% CI 3.2-12.6%), demonstrating an absolute reduction of 20.0% (95% CI 12.2-27.7%, p < 0.05). Interventions resulted in a significant decrease in abdominal/pelvic CT imaging corresponding with special cause variation. No clinically significant intra-abdominal injuries were missed. CONCLUSIONS: This quality improvement initiative reduced abdominal/pelvic CT rates in pediatric trauma patients at low risk for intra-abdominal injury without any missed cases of significant injury. Leveraging standardized decision tools to reduce unnecessary CT imaging can be successfully accomplished without compromising care.

RéSUMé: OBJECTIF: Les lésions intra-abdominales surviennent dans moins de 15 % des activations de traumatismes pédiatriques, mais peuvent mettre la vie en danger. L'imagerie par tomodensitométrie (TDM) est couramment prescrite en cas de traumatisme pédiatrique, même lorsque le risque de lésion intra-abdominale est faible. Nous avons cherché à réduire les taux de tomodensitométrie abdominale/pelvienne chez les enfants à très faible risque de lésion intra-abdominale nécessitant l'activation d'un traumatisme dans notre centre de traumatologie pédiatrique. MéTHODES: Nous avons mis en œuvre une initiative d'amélioration de la qualité à l'aide du modèle d'amélioration chez les enfants de 0-15,99 ans qui ont activé une réaction traumatique et ont été évalués pour les lésions intra-abdominales. Les interventions comprenaient une aide à la décision clinique, une formation institutionnelle, ainsi qu'un audit et un retour d'information individuels. Notre principal résultat a été le taux de TDM abdominale/pelvienne chez les patients à très faible risque de lésion intra-abdominale. Les mesures d'équilibre comprenaient les tomodensitométries demandées dans les 24 heures suivant l'évaluation aux urgences et le retour aux urgences ou l'hospitalisation dans les 72 heures en cas de lésion intra-abdominale manquée. Le contrôle statistique des processus a été utilisé pour évaluer les taux au fil du temps. RéSULTATS: La période de référence (du 1er avril 2016 au 30 novembre 2017) comprenait 359 patients traumatisés ayant un taux de tomodensitométrie de 26,8 % (IC à 95 % de 20,5 % à 33,8 %) chez ceux qui présentaient un faible risque de lésion intra-abdominale. La période d'intervention (1er décembre 2017-31 décembre 2019) a inclus 445 patients avec un taux de TDM chez les patients à faible risque de 6,8 % (IC à 95 % de 3,2 % à 12,6 %), démontrant une réduction absolue de 20,0 % (IC à 95 % 12,2 % à 27,7 %, p < 0,05). Les interventions ont entraîné une diminution significative de l'imagerie TDM abdominale/pelvienne correspondant à une variation de cause particulière. Aucune lésion intra-abdominale cliniquement significative n'a été manquée. CONCLUSIONS: Cette initiative d'amélioration de la qualité a réduit les taux de TDM abdominale/pelvienne chez les patients pédiatriques traumatisés à faible risque de lésion intra-abdominale sans qu'il y ait de cas manqués de blessure importante. Il est possible d'utiliser des outils de décision standardisés pour réduire les examens d'imagerie par scanner inutiles sans compromettre les soins.

Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review.

INTRODUCTION: Evidence suggests the presence of deficiencies in the quality of care provided to up to half of all paediatric trauma patients in Canada, the USA and Australia. Lack of adherence to evidence-based recommendations may be driven by lack of knowledge of clinical practice guidelines (CPGs), heterogeneity in recommendations or concerns about their quality. We aim to systematically review CPG recommendations for paediatric injury care and appraise their quality. METHODS AND ANALYSIS: We will identify CPG recommendations through a comprehensive search strategy including Medical Literature Analysis and Retrieval System Online, Excerpta Medica dataBASE, Cochrane library, Web of Science, ClinicalTrials and websites of organisations publishing recommendations on paediatric injury care. We will consider CPGs including at least one recommendation targeting paediatric injury populations on any diagnostic or therapeutic intervention from the acute phase of care with any comparator developed in high-income countries in the last 15 years (January 2007 to a maximum of 6 months prior to submission). Pairs of reviewers will independently screen titles, abstracts and full text of eligible articles, extract data and evaluate the quality of CPGs and their recommendations using Appraisal of Guidelines Research and Evaluation (AGREE) II and AGREE Recommendations Excellence instruments, respectively. We will synthesise evidence on recommendations using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Evidence-to-Decision framework and present results within a recommendations matrix. ETHICS AND DISSEMINATION: Ethics approval is not a requirement as this study is based on available published data. The results of this systematic review will be published in a peer-reviewed journal, presented at international scientific meetings and distributed to healthcare providers. PROSPERO REGISTRATION NUMBER: International Prospective Register of Systematic Reviews (CRD42021226934).

Acute injury or illness related to the inhalation of vaping aerosols among children and adolescents across Canada: A cross-sectional survey of Canadian paediatricians.

Background: Vaping prevalence rates have increased among Canadian youth. Evidence suggests that vaping poses significant health risks to children and adolescents. Objectives: The objectives of the study were to investigate epidemiological characteristics of acute injury/illness cases due to the inhalation of vaping aerosols among children and adolescents across Canada and to explore factors contributing to severe cases. Methods: Data from the 2019 Canadian Paediatric Surveillance Program cross-sectional survey on vaping-related injury/illness were used. Analyses focused on injury/illness cases (n=71) among children and adolescents aged 0 to 17 years who presented to participating paediatricians for a harm related to the inhalation of vaping aerosols. We conducted descriptive analyses and performed logistic regression to explore associations between severe presentations requiring hospitalization or intensive care unit (ICU) admission and selected case characteristics. Results: Of the 71 reported injury/illness cases related to inhalation of vaping aerosols, 56% of patients were male, and 68% were aged 15 to 17 years. Nicotine vaping was reported in 42% of cases, and cannabis vaping in 24%. Fifty-four per cent presented with respiratory distress, 18% with symptoms of nicotine toxicity, and 41% required hospitalization and/or admission to the ICU. Cases presenting with respiratory distress were more likely to be hospitalized/admitted to the ICU (odds ratio [OR]=5.37, 95% confidence interval [CI]:1.76 to 16.39). Conclusions: The inhalation of vaping aerosols among children and adolescents may contribute to acute injury/illness. Clear associations between study variables and severe cases could not be established due to a small sample size. Additional research is needed to determine predictors and preventable risk factors of severe vaping-related injuries.

The association of intraosseous vascular access and survival among pediatric patients with out-of-hospital cardiac arrest.

INTRODUCTION: In pediatric out-of-hospital cardiac arrest (OHCA) the effect of intraosseous (IO) or intravenous (IV) access on outcomes is unclear. METHODS: We analyzed prospectively collected data of non-traumatic OHCA in the Resuscitation Outcomes Consortium registry from 2011 to 2015. We included EMS-treated patients ≤17 years of age, classified patients based on vascular access routes, and calculated success rates of IO and IV attempts. After excluding patients with obvious non-cardiac etiologies and those with unsuccessful vascular access or multiple routes, we fit a logistic regression model to evaluate the association of IO vascular access (reference IV access) with the primary outcome of survival, using multiple imputation to address missing data. We analyzed a subgroup of patients at least 2 years of age. RESULTS: There were 1549 non-traumatic OHCA: 895 (57.8%) patients had an IO line attempted with 822 (91.8%) successful; 488 (31.5%) had an IV line attempted with 345 (70.7%) successful (difference 21%, 95% CI 17 to 26%). Of the 761 patients included in our logistic regression, 601 received IO (30 [5.2%] survived) and 160 received IV (40 [25%] survived) vascular access. Intraosseous access was associated with a decreased probability of survival (adjusted OR 0.46; 95% CI 0.21-0.98). Patients at least 2 years of age showed a similar association (adjusted OR 0.36; CI 0.15-0.86). CONCLUSIONS: Intraosseous access was associated with decreased survival among pediatric non-traumatic OHCA. These results are exploratory and support the need for further study to evaluate the effect of intravascular access method on outcomes.

Coronavirus disease 2019 in the pediatric emergency department: unique considerations in preparation and response.

PURPOSE OF REVIEW: Pediatric Emergency Departments (PEDs) have experienced unique considerations throughout the coronavirus disease 2019 (COVID-19) pandemic. We review the adaptations and challenges surrounding the preparation and response for pediatric emergency patients, with a specific focus on operational modifications, evolving personal protected equipment (PPE) needs, protected resuscitation responses, clinical characteristics in children, and the unintended effects on children and youth. RECENT FINDINGS: COVID-19 has thus far proven to have a milder course in children, with manifestations ranging from asymptomatic carriage or typical viral symptoms, to novel clinical entities such as 'COVID toes' and multisystem inflammatory syndrome in children (MIS-C), the latter associated with potentially significant morbidity. It has had an important effect on primary prevention, injury rates, reduced presentations for emergency care, and increased mental health, abuse and neglect rates in children and youth. PEDs have prepared successfully. The most significant adjustments have occurred with screening, testing, and consistent and effective use of PPE, along with protected responses to resuscitation, adaptations to maintain family-centered care, and technological advances in communication and virtual care. Simulation has been key to the successful implementation of many of these strategies. SUMMARY: COVID-19 has pushed PEDs to rapidly adapt to evolving clinical and societal needs, with both resultant challenges and positive advances. Further experience and research will guide how in the face of a global pandemic we can further optimize the clinical and operational care of children and youth, ensure robust educational training programs, and maintain provider safety and wellness.

Vaping-related injury and illness among Canadian children and adolescents: a one-time survey of paediatric providers.

A one-time survey distributed to 2693 Canadian paediatricians enrolled in the Canadian Paediatric Surveillance Programme was conducted between October and December 2019. We identified a wide range of severe vaping-related injuries and illnesses among children ages 0-17 (n=88), which were associated with the routine use or malfunctioning of a vaping device or the ingestion of vaping substances. The most common clinical presentations were acute respiratory symptoms and nicotine toxicity and 15% (n=13) of injuries required intensive care unit admission. Our study highlights the urgent need for substantive policy measures to help protect youth against the risks associated with vaping products.

Vaping implications for children and youth.

PURPOSE OF REVIEW: The development and uptake of E cigarettes are a relatively recent phenomenon. Because of aggressive marketing, attractive designs, enticing flavors and primarily reactionary legislation, we are now seeing soaring rates of adolescent vaping with associated consequences. This review explores how E cigarettes work, their health implications, epidemiology among youth and current regulatory strategies. RECENT FINDINGS: Recently, the Center for Disease Control and Prevention reported that 27% of high school students had used a tobacco product within the last month, the majority being E-cigarettes in 20.8% of high school students. Vaping has managed to reverse a decades long trend of declining nicotine use among youth. Long-term addiction is not the only concern related to youth vaping; there are also increasing reports of short-term health consequences, such as seizures, acute nicotine toxicity, burns and lung injury. SUMMARY: Industry has created and aggressively marketed a product that is enticing to adolescents. E cigarettes have sleek designs, desirable flavors and social acceptability with perceived safety among youth. This has resulted in epidemic E cigarette use in youth with resultant significant short-term and long-term health concerns. Legislation must include regulations that strictly avoid marketing and sales to youth, as well as reducing access to these products.