Intranasal Fentanyl to Reduce Pain and Improve Oral Intake in the Management of Children With Painful Infectious Mouth Lesions.

OBJECTIVES: Painful infectious mouth conditions such as herpangina, hand-foot-and-mouth disease, and herpetic gingivostomatitis can cause pain, dehydration, and hospitalization in young children. Treatment for these conditions is generally supportive and directed toward pain relief from ulcerative lesions, thus facilitating oral intake, and preventing dehydration. Attempts at oral therapy at home and in the emergency department are often refused and immediately spit back out. This study evaluated the efficacy of intranasal fentanyl (INF) compared with a commonly used oral (PO) acetaminophen/hydrocodone formulation for the treatment of children with painful infectious mouth conditions. METHODS: This study was a prospective, nonblinded, randomized controlled noninferiority trial conducted in an academic tertiary care pediatric emergency department. The study enrolled children between the ages of 6 months and 18 years with painful infectious mouth lesions and poor oral intake. Patients were randomized to receive either INF (1.5 µg/kg, intervention) or PO acetaminophen/hydrocodone (0.15 mg/kg, control) based on the dose of hydrocodone. The primary outcome was volume of fluid intake per body weight (in milliliters per kilogram) 60 minutes after analgesic administration. Secondary outcomes included pain scores using a validated visual assessment scale (VAS; 1, no pain; 10, worst pain), hydration score (VAS; 1, well hydrated; 4, very dehydrated), admission rate and overall satisfaction score (VAS; 1, worst; 7, best). A priori power analysis indicated that 34 patients would achieve an 81% power with an α value of 0.05. RESULTS: Of the 34 patients enrolled, 17 were randomized to INF and 17 to PO. The demographics between both groups were similar in age, weight, sex, and race. There were no significant differences in parental perception of pain ( P = 0.69) or hydration status ( P = 0.78). Oral fluid intake at 60 minutes was 20 mL/kg for INF versus 18 mL/kg for PO ( P = 0.53). Pain scores at 15 and 30 minutes were 1.7 versus 2.9 ( P = 0.09) and 0.6 versus 1.6 ( P = 0.59). Parental perceptions of pain and hydration status at 60 minutes were 2.2 versus 2.4 ( P = 0.77) and 1.7 versus 1.5 ( P = 0.37). Overall parental satisfaction was 6.4 for INF versus 6.5 for PO ( P = 0.71), and admission rate was 0 vs 12% ( P = 0.49). There were no adverse events such as respiratory, cardiac, or central nervous system depression in either group. CONCLUSIONS: Intranasal fentanyl seems to be a safe and effective alternative to acetaminophen with hydrocodone in reducing pain and improving hydration status in children with painful infectious mouth lesions and poor oral intake.

A Pilot Study Testing Intranasal Ketamine for the Treatment of Procedural Anxiety in Children Undergoing Laceration Repair.

Identifying non-invasive methods for anxiolysis is becoming increasingly important in the pediatric emergency department (ED). Few studies have examined the use of intranasal (IN) ketamine for procedural anxiolysis. We aim to evaluate if IN ketamine provides satisfactory anxiolysis for patients undergoing laceration repair based on anxiety and sedation scoring. We also evaluated the feasibility of using IN ketamine in future trials based on its tolerability and side-effects. A pilot study evaluating IN ketamine in the treatment of procedural anxiety for patients, 2 years and older, weighing 40 kg or less, presenting to the pediatric ED with lacerations. The need for anxiolysis was defined by an elevated modified-Yale Preoperative Anxiety Scale-Short Form (mYPAS-SF) score. Patients received 5 mg/kg of IN ketamine in addition to topical anesthesia, mYPAS-SF scoring before and during the procedure, sedation scoring, adverse events, vital signs, age, weight, laceration size and location, and satisfaction surveys were recorded. Twenty-five patients were enrolled, with mean age of 61 ± 29.2 months and mean weight of 21 ± 6.4 kg. Lacerations were located on the face, extremities, and groin with mean size of 2.1 cm. A decrease in anxiety levels was observed, from median m-YPAS-SF score of 66.7 (62.50-80.2) to 33.3 (27.09-52.00), p < 0.001. Among the patients, 92% (n = 23) were less anxious during the procedure. IN ketamine appears to be safe and well-tolerated with a positive impact on procedural anxiety. A dosage of 5 mg/kg is a reasonable starting point, as 80% of patients had appropriate anxiolysis.

Evaluation of an Online Educational Tool to Improve Postresuscitation Debriefing in the Emergency Department.

OBJECTIVE: Postresuscitation debriefing (PRD) addresses Accreditation Council for Graduate Medical Education core competencies and is recommended by the American Heart Association. Postresuscitation debriefing improves resuscitation outcomes, promotes team morale, supports emotional well-being, and reduces burnout. Despite these benefits, PRD occurs infrequently. Commonly cited barriers to PRD include lack of training and comfort in facilitating PRD. We are unaware of any video-based educational tools that train physicians in PRD. We aimed to evaluate the impact of an educational tool on the frequency of PRD using a before- and after-study design. METHODS: We created and distributed a 20-minute, video-based educational tool via youtube.com on PRD to pediatric emergency medicine (EM) fellows, pediatric EM attendings, senior EM residents, and EM attending physicians. Participants completed web-based surveys before, immediately after, and 3 months after watching the tool. We analyzed the effects of participation on PRD knowledge, comfort conducting PRD, and frequency of PRD performance. RESULTS: Thirty-five (63%) of 56 participants completed all 3 surveys. Participation in our study showed significant improvements in reported frequency of performing PRD (23% presurvey, 38% follow-up survey; 95% confidence interval [CI], 2%-29%; P = 0.03), perceived knowledge of PRD (odds ratio, 6.1; 95% CI, 3.05-12.29; P < 0.001), and comfort in conducting PRD (odds ratio, 3.7; 95% CI, 1.96-7.03; P < 0.001). Most respondents (94%) reported that the tool was worthwhile. Most (83%) would recommend the tool to colleagues, and 86% reported positive effects on their teams with PRD. CONCLUSIONS: Implementation of a video-based educational tool on PRD in the emergency department was associated with increased provider report of PRD frequency, knowledge, and comfort level.

Trimming the fat: identification of risk factors associated with obesity in a pediatric emergency department.

OBJECTIVE: The purpose of this study was to assess which knowledge deficits and dietary habits in an urban pediatric emergency department (ED) population are risk factors for obesity. METHODS: This cross-sectional study in an urban pediatric ED used a modified version of the Diet and Health Knowledge Survey, an in-person interview questionnaire, to collect data on demographics, dietary knowledge, and practices. All patients aged 2 to 17 years were enrolled in the study over a 4-month period. Subjects were excluded if they were in extremis, pregnant, incarcerated, institutionalized, considered an emancipated minor, or consumed only a modified consistency diet. RESULTS: One hundred seventy-nine subjects were enrolled in this study. Based on body mass index, the prevalence of obesity in our study population was 24%. Parents with obese children answered a mean of 62.9% (95% confidence interval, 60.4%-65.5%) of knowledge questions correctly, whereas all others scored 60.3% (95% confidence interval, 58.3%-62.3%) correctly. Based on the univariate analysis, 10 predictors met inclusion criteria into logistic regression analysis: screen time (P = 0.03), race (P = 0.08), sex (P = 0.04), parental education (P = 0.08), parental estimation that child is overweight (P < 0.0001), parental estimation that child is underweight (P = 0.003), trimming fat from meat (P = 0.06), soft-drink consumption (P = 0.03), exercise (P = 0.07), and chip consumption (P = 0.04). In a multivariate analysis, only male sex, regularly trimming fat from meat, and parental assessment of obesity were independently associated with obesity. CONCLUSIONS: Knowledge deficiencies regarding healthy nutrition among parents in an urban pediatric ED population were not significantly associated with having obese children; however, specific habits were. Emergency physicians may provide a valuable role in identification and brief behavioral intervention in high-risk populations during the current epidemic of childhood obesity.

What are you waiting for? A study of resident physician-parent communication in a pediatric emergency department.

STUDY OBJECTIVE: This study measures the degree to which parents of patients, in the course of evaluation and treatment in a pediatric emergency department (ED), could report what they were waiting for. METHODS: Brief in-person interviews were conducted with parents of nonemergency patients during an ED visit. After the patient had been seen by a resident physician and evaluation and treatment were in progress, parents were asked to report what they were waiting for. The patient's physician was also asked to report what the patient was waiting for. These answers were compared and coded as complete agreement, partial agreement, or disagreement. Association between lack of agreement and patient factors (age, sex), parent factors (sex, education, age), physician factors (sex, postgraduate year), and system factors (wait time, time of day, number of patients in the department) was examined. Logistic regression was used to calculate adjusted odds ratios. RESULTS: A total of 200 paired surveys were included in the data analysis. Two thirds of parental reports completely agreed with physician reports, 11.5% partially agreed, and 21.5% completely disagreed. Multivariate analysis revealed that disagreement between resident physician and parents was associated with parental educational level and physician training level. Parents with less than a high school education were more than 9 times more likely to disagree than those with at least some college education (odds ratio 9.3; 95% confidence interval [CI] 2.4 to 35.7). As the postgraduate level of the physician decreased, disagreement was more common; disagreement for patients of postgraduate level 1 residents was 5 times more likely (95% CI 1.8 to 14.5) than that of postgraduate level 3 and higher residents. CONCLUSION: As measured by asking the question "what are you waiting for," significant communication gaps were identified between physicians and the parents of their patients in this emergency department. One in five parents could not report what they were waiting for. Factors such as lower parental education and less physician experience increase the risk of such a gap. Further work in defining the source of the ineffective communication and interventions to remediate the problem is needed.

An infant with tachypnea.

The purpose of this case report is to illustrate the diagnostic difficulties of congestive heart failure in an infant. When presenting to the emergency department, these patients are often evaluated for sepsis, congenital heart disease, metabolic disorders, and myocarditis. We report a case of a 3(1/2)-month-old male who presented to the pediatric emergency department with congestive heart failure. He was found to have vitamin D deficiency rickets induced cardiomyopathy.