Survival After Intra-Arrest Transport vs On-Scene Cardiopulmonary Resuscitation in Children.

Importance: For pediatric out-of-hospital cardiac arrest (OHCA), emergency medical services (EMS) may elect to transport to the hospital during active cardiopulmonary resuscitation (CPR) (ie, intra-arrest transport) or to continue on-scene CPR for the entirety of the resuscitative effort. The comparative effectiveness of these strategies is unclear. Objective: To evaluate the association between intra-arrest transport compared with continued on-scene CPR and survival after pediatric OHCA, and to determine whether this association differs based on the timing of intra-arrest transport. Design, Setting, and Participants: This cohort study included pediatric patients aged younger than 18 years with EMS-treated OHCA between December 1, 2005 and June 30, 2015. Data were collected from the Resuscitation Outcomes Consortium Epidemiologic Registry, a prospective 10-site OHCA registry in the US and Canada. Data analysis was performed from May 2022 to February 2024. Exposures: Intra-arrest transport, defined as an initiation of transport prior to the return of spontaneous circulation, and the interval between EMS arrival and intra-arrest transport. Main Outcomes and Measures: The primary outcome was survival to hospital discharge. Patients who underwent intra-arrest transport at any given minute after EMS arrival were compared with patients who were at risk of undergoing intra-arrest transport within the same minute using time-dependent propensity scores calculated from patient demographics, arrest characteristics, and EMS interventions. We examined subgroups based on age (<1 year vs ≥1 year). Results: Of 2854 eligible pediatric patients (median [IQR] age, 1 [0-9] years); 1691 males [59.3%]) who experienced OHCA between December 2005 and June 2015, 1892 children (66.3%) were treated with intra-arrest transport and 962 children (33.7%) received continued on-scene CPR. The median (IQR) time between EMS arrival and intra-arrest transport was 15 (9-22) minutes. In the propensity score-matched cohort (3680 matched cases), there was no significant difference in survival to hospital discharge between the intra-arrest transport group and the continued on-scene CPR group (87 of 1840 patients [4.7%] vs 95 of 1840 patients [5.2%]; risk ratio [RR], 0.81 [95% CI, 0.59-1.10]). Survival to hospital discharge was not modified by the timing of intra-arrest transport (P value for the interaction between intra-arrest transport and time to matching = .10). Among patients aged younger than 1 year, intra-arrest transport was associated with lower survival to hospital discharge (RR, 0.52; 95% CI, 0.33-0.83) but there was no association for children aged 1 year or older (RR, 1.22; 95% CI, 0.77-1.93). Conclusions and Relevance: In this cohort study of a North American OHCA registry, intra-arrest transport compared with continued on-scene CPR was not associated with survival to hospital discharge among children with OHCA. However, intra-arrest transport was associated with a lower likelihood of survival to hospital discharge among children aged younger than 1 year.

Race, Ethnicity, Language, and the Treatment of Low-Risk Febrile Infants.

Importance: Febrile infants at low risk of invasive bacterial infections are unlikely to benefit from lumbar puncture, antibiotics, or hospitalization, yet these are commonly performed. It is not known if there are differences in management by race, ethnicity, or language. Objective: To investigate associations between race, ethnicity, and language and additional interventions (lumbar puncture, empirical antibiotics, and hospitalization) in well-appearing febrile infants at low risk of invasive bacterial infection. Design, Setting, and Participants: This was a multicenter retrospective cross-sectional analysis of infants receiving emergency department care between January 1, 2018, and December 31, 2019. Data were analyzed from December 2022 to July 2023. Pediatric emergency departments were determined through the Pediatric Emergency Medicine Collaborative Research Committee. Well-appearing febrile infants aged 29 to 60 days at low risk of invasive bacterial infection based on blood and urine testing were included. Data were available for 9847 infants, and 4042 were included following exclusions for ill appearance, medical history, and diagnosis of a focal infectious source. Exposures: Infant race and ethnicity (non-Hispanic Black, Hispanic, non-Hispanic White, and other race or ethnicity) and language used for medical care (English and language other than English). Main Outcomes and Measures: The primary outcome was receipt of at least 1 of lumbar puncture, empirical antibiotics, or hospitalization. We performed bivariate and multivariable logistic regression with sum contrasts for comparisons. Individual components were assessed as secondary outcomes. Results: Across 34 sites, 4042 infants (median [IQR] age, 45 [38-53] days; 1561 [44.4% of the 3516 without missing sex] female; 612 [15.1%] non-Hispanic Black, 1054 [26.1%] Hispanic, 1741 [43.1%] non-Hispanic White, and 352 [9.1%] other race or ethnicity; 3555 [88.0%] English and 463 [12.0%] language other than English) met inclusion criteria. The primary outcome occurred in 969 infants (24%). Race and ethnicity were not associated with the primary composite outcome. Compared to the grand mean, infants of families that use a language other than English had higher odds of the primary outcome (adjusted odds ratio [aOR]; 1.16; 95% CI, 1.01-1.33). In secondary analyses, Hispanic infants, compared to the grand mean, had lower odds of hospital admission (aOR, 0.76; 95% CI, 0.63-0.93). Compared to the grand mean, infants of families that use a language other than English had higher odds of hospital admission (aOR, 1.08; 95% CI, 1.08-1.46). Conclusions and Relevance: Among low-risk febrile infants, language used for medical care was associated with the use of at least 1 nonindicated intervention, but race and ethnicity were not. Secondary analyses highlight the complex intersectionality of race, ethnicity, language, and health inequity. As inequitable care may be influenced by communication barriers, new guidelines that emphasize patient-centered communication may create disparities if not implemented with specific attention to equity.

The impact of a novel policy for pediatric mental health patients in the emergency department.

OBJECTIVES: Pediatric mental health presentations continue to increase across the US. These patients often board for significant periods of time and may require more resources than other acute non-mental health patients. This has important implications for the overall function of the emergency department (ED) as well as care of all ED patients. METHODS: This study evaluated a policy developed to allow for inpatient hospital admission when 30% of the ED was occupied by boarding patients at a tertiary care children's hospital. RESULTS: We found an increase in the number of patients for whom this policy applied, and increased days/month this policy was executed over time. There was an increase in the average ED LOS and left without being seen rate during this time which we hypothesize would have been higher without this policy. CONCLUSIONS: A hospital policy allowing mental health patients to be admitted to the inpatient hospital once stabilized has the potential to improve ED flow and functionality.

A Quest for Better Strategy in Pediatric Intraosseous Placement Using Radiographic Measurements in Patients Younger Than 2 Years.

ABSTRACT: Intraosseous (IO) needles are used to obtain vascular access in pediatric patients during emergent situations. Recent literature has raised concern about high rates of IO malposition in younger children. Despite the widespread use of IO access in the pediatric population, there is scarce evidence regarding the ideal needle length or optimal access site. This study uses a radiographic approach to determine the appropriate IO needle length and access site to minimize the risk of malposition in children younger than 2 years. Radiographs of the lower extremities were obtained from the electronic database from a single tertiary care center. Using lateral views, anteroposterior measurements were obtained at 2 axial planes, located 1 cm superior to distal femur physis and 1 cm inferior to distal tibia physis. Based on the measurements, we calculated the probable needle tip positions if the needle was placed to the hub at the skin level using the EZ-IO (Teleflex Ltd, Wayne, PA) preset needle sizes. For subjects younger than 6 months, the 25-mm needle minimized malposition in the femur site with a 45.7% appropriate position rate, and the 15-mm needle minimized malposition in the tibia site with a 57.1% appropriate position rate. For the older age groups, we did not find a standard needle that would consistently minimize malposition in the femur site. For the tibia site, the 25-mm needle minimized malposition risk, with appropriate position rates of 81.0%, 87.5%, and 91.1% in the 6- to 12-month, 13- to 18-month, and 19- to 24-month groups, respectively.

Factors associated with US caregivers' uptake of pediatric COVID-19 vaccine by race and ethnicity.

OBJECTIVES: To assess differences in willingness to vaccinate children against COVID-19, and factors that may be associated with increased acceptance, among US caregivers of various racial and ethnic identities who presented with their child to the Emergency Department (ED) after emergency use authorization of vaccines for children ages 5-11. STUDY DESIGN: A multicenter, cross-sectional survey of caregivers presenting to 11 pediatric EDs in the United States in November-December 2021. Caregivers were asked about their identified race and ethnicity and if they planned to vaccinate their child. We collected demographic data and inquired about caregiver concerns related to COVID-19. We compared responses by race/ethnicity. Multivariable logistic regression models served to determine factors that were independently associated with increased vaccine acceptance overall and among racial/ethnic groups. RESULTS: Among 1916 caregivers responding, 54.67% planned to vaccinate their child against COVID-19. Large differences in acceptance were noted by race/ethnicity, with highest acceptance among Asian caregivers (61.1%) and those who did not specify a listed racial identity (61.1%); caregivers identifying as Black (44.7%) or Multi-racial (44.4%) had lower acceptance rates. Factors associated with intent to vaccinate differed by racial/ethnic group, and included caregiver COVID-19 vaccine receipt (all groups), caregiver concerns about COVID-19 (White caregivers), and having a trusted primary provider (Black caregivers). CONCLUSIONS: Caregiver intent to vaccinate children against COVID-19 varied by race/ethnicity, but race/ethnicity did not independently account for these differences. Caregiver COVID-19 vaccination status, concerns about COVID-19, and presence of a trusted primary provider are important in vaccination decisions.

Should COVID-19 vaccines be mandated in schools? - an international caregiver perspective.

OBJECTIVES: Caregiver attitudes toward mandating COVID-19 vaccines for their children are poorly understood. We aimed to determine caregiver acceptability of COVID-19 vaccine mandates for schools/daycares and assess if opposition to mandates would result in removal of children from the educational system. STUDY DESIGN: Perform a cross-sectional, anonymous survey of adult caregivers with children ≤ 18 years presenting to 21 pediatric emergency departments in the United States, Canada, Israel, and Switzerland, November 1st through December 31st, 2021. The primary outcome was caregiver acceptance rates for school vaccine mandates, and the secondary outcomes included factors associated with mandate acceptance and caregiver intention to remove the child from school. RESULTS: Of 4,393 completed surveys, 37% of caregivers were opposed to any school vaccine mandate. Caregiver acceptance was lowest for daycare settings (33%) and increased as the child's level of education increased, college (55%). 26% of caregivers report a high likelihood (score of 8-10 on 0-10 scale) to remove their child from school if the vaccine became mandatory. Child safety was caregivers' greatest concern over vaccine mandates. A multivariable model demonstrated intent to vaccinate their child for COVID-19 (OR = 8.9, 95% CI 7.3 to 10.8; P < 0.001) and prior COVID-19 vaccination for the caregiver (OR = 3.8, 95% CI 3.0 to 4.9; P < 0.001) had the greatest odds of increasing mandate acceptance for any school level. CONCLUSIONS: Many caregivers are resistant to COVID-19 vaccine mandates for schools, and acceptance varies with school level. One-fourth of caregivers plan to remove their child from the educational system if vaccines become mandated.

Prehospital Epinephrine Use in Pediatric Anaphylaxis by Emergency Medical Services.

OBJECTIVES: Anaphylaxis requires prompt assessment and management with epinephrine to reduce its morbidity and mortality. This study examined the prehospital management of pediatric anaphylactic reactions in Northeast Ohio. METHODS: This is a retrospective chart review using emergency medical service (EMS) run charts of patients 18 years and younger from February 2015 to April 2019. Patient charts with the diagnosis of "anaphylaxis" or "allergic reaction" were reviewed and confirmed that symptoms met anaphylaxis criteria. Information regarding epinephrine administration before EMS arrival and medications given by EMS providers was collected. Analysis was performed using descriptive statistics. RESULTS: From 646 allergic/anaphylactic reaction EMS run charts, 150 (23%) met the guideline criteria for anaphylaxis. The median patient age was 12 years. Only 57% (86/150) of these patients received intramuscular epinephrine, and the majority received it before EMS arrival. Epinephrine was administered by EMS to 32% (30/94; 95% confidence interval [CI], 22.7% to 42.3%) of patients who had not already received epinephrine. The odds of receiving prehospital epinephrine were significantly lower for patients 5 years and younger (risk difference [RD], -0.23; 95% CI, -0.43 to -0.04), those with no history of allergic reaction (RD, -0.20; 95% CI, -0.38 to -0.03), those who presented with lethargy (RD, -0.43; 95% CI, -0.79 to -0.06), and those whose trigger was a medication or environmental allergen (RD, -0.47; 95% CI, -0.72 to -0.23 for each). CONCLUSIONS: Emergency medical service providers in this region demonstrated similar use of epinephrine as reported elsewhere. However, 43% (64/150) of pediatric patients meeting anaphylaxis criteria did not receive prehospital epinephrine, and 10% (15/150) received no treatment whatsoever. Efforts to improve EMS provider recognition and prompt epinephrine administration in pediatric cases of anaphylaxis seem necessary.

Comparative Analysis of Performance Factors between Ladies Professional Golf Association and Korea Ladies Professional Golf Association Golfers.

This study aimed to analyze the performance factors of both Ladies Professional Golf Association (LPGA) and Korea Ladies Professional Golf Association (KLPGA) players and suggest which performance factors they should improve to play in world-level games. Data from 180 LPGA and KLPGA players who ranked within the top 60 in prize money rankings from 2018 to 2020 were analyzed. Then, the data from LPGA and KLPGA golfers were compared using the seemingly unrelated estimation method. As a result of analyzing 178 data, excluding two players who had missing values, this study found that among LPGA player data, putting average (PA), sand save (SS), green in regulation (GIR), and birdies (BIR) had a significant impact in 2018. Additionally, scoring average (SA) and top-10 finish (T10) had a significant impact in 2019. However, there were no factors influencing performance in 2020.From the results of analyzing 180 players who ranked within the top 60 in KLPGA prize money rankings, there were no performance factors that significantly affected their performance in 2018. However, driver distance (DD) in 2019 and DD and T10 in 2020 affected performance. In conclusion, short games were the most important factor on the LPGA Tour, and driving distance was the most important trend on the KLPGA Tour. Therefore, KLPGA golfers should train in abilities such as putting and ironshots.

Sweet and Salty: Diabetic Ketoacidosis in a Patient With Nephrogenic Diabetes Insipidus.

The co-existence of nephrogenic diabetes insipidus (NDI) with diabetes mellitus (DM) in a patient that presents in diabetic ketoacidosis (DKA) is rare and, to our knowledge, has not been described even in case reports. We report the case of a 16-year-old male with known NDI who presented to the pediatric emergency department (ED) for one day with generalized weakness and decreased appetite, found to be in moderate DKA from new-onset DM. The initial management of his dehydration and hyperosmolar state presented a unique challenge. Fluid resuscitation with isotonic fluids in a patient with NDI poses a risk of worsening hypernatremia, which can lead to seizures and death. However, the use of hypotonic fluids has the potential to lower serum osmolality too quickly, which can result in cerebral edema. Nephrology, endocrinology, and the pediatric intensive care unit (PICU) consultants were notified of this patient, and a discussion was coordinated between sub-specialists to determine the appropriate fluid resuscitation. The patient was allowed to drink free water in addition to receiving intravenous fluids (IVF) of dextrose 5% with 0.2% sodium chloride at a rate of one-and-a-half maintenance (150 mL/hr) in the ED prior to transfer to the PICU where insulin infusion was initiated. This case report provides guidance to inpatient providers on the management of patients with co-existent NDI and DM in DKA, a rare combination that requires thoughtful and urgent management.