Household Transmission Dynamics of Asymptomatic SARS-CoV-2-Infected Children: A Multinational, Controlled Case-Ascertained Prospective Study.

BACKGROUND: Asymptomatic SARS-CoV-2 infection in children is highly prevalent but its acute and chronic implications have been minimally described. METHODS: In this controlled case-ascertained household transmission study, we recruited asymptomatic children <18 years with SARS-CoV-2 nucleic acid testing performed at 12 tertiary care pediatric institutions in Canada and the United States. We attempted to recruit all test-positive children and 1 to 3 test-negative, site-matched controls. After 14 days' follow-up we assessed the clinical (ie, symptomatic) and combined (ie, test-positive, or symptomatic) secondary attack rates (SARs) among household contacts. Additionally, post-COVID-19 condition (PCC) was assessed in SARS-CoV-2-positive participating children after 90 days' follow-up. RESULTS: A total of 111 test-positive and 256 SARS-CoV-2 test-negative asymptomatic children were enrolled between January 2021 and April 2022. After 14 days, excluding households with co-primary cases, the clinical SAR among household contacts of SARS-CoV-2-positive and -negative index children was 10.6% (19/179; 95% CI: 6.5%-16.1%) and 2.0% (13/663; 95% CI: 1.0%-3.3%), respectively (relative risk = 5.4; 95% CI: 2.7-10.7). In households with a SARS-CoV-2-positive index child, age <5 years, being pre-symptomatic (ie, developed symptoms after test), and testing positive during Omicron and Delta circulation periods (vs earlier) were associated with increased clinical and combined SARs among household contacts. Among 77 asymptomatic SARS-CoV-2-infected children with 90-day follow-up, 6 (7.8%; 95% CI: 2.9%-16.2%) reported PCC. CONCLUSIONS: Asymptomatic SARS-CoV-2-infected children, especially those <5 years, are important contributors to household transmission, with 1 in 10 exposed household contacts developing symptomatic illness within 14 days. Asymptomatic SARS-CoV-2-infected children may develop PCC.

Management of pediatric toxic ingestions in the emergency department.

Pediatric ingestions present a common challenge for emergency clinicians. While findings and information from the physical examination, electrocardiographic, laboratory, and radiologic testing may suggest a specific ingestion, timely identification of many substances is not always possible. In addition to diagnostic challenges, the management of many ingested substances is controversial and recommendations are evolving. This issue reviews the initial resuscitation, diagnosis, and treatment of common pediatric ingestions. Also discussed are current recommendations for decontamination and administration of antidotes for specific toxins.

Strategic Surge Responses in the COVID-19 era: Operational Themes, Innovative Solutions and Lessons Learned by Three Freestanding Pediatric Emergency Departments.

The prolonged COVID-19 pandemic has created unique and complex challenges in operational and capacity planning for pediatric emergency departments, as initial low pediatric patient volumes gave way to unpredictable patient surges during Delta and Omicron variants. Compounded by widespread hospital supply chain issues, staffing shortages due to infection and attrition, and a concurrent pediatric mental health crisis, the surges have pushed pediatric emergency department leaders to re-examine traditionally defined clinical processes, and adopt innovative operational strategies. This study describes the strategic surge response and lessons learned by 3 major freestanding academic pediatric emergency departments in the western United States to help inform current and future pediatric pandemic preparedness.

Near-peer mentoring and virtual reality for adult basic life support education in high school students.

Bystander cardiopulmonary resuscitation (CPR) can improve cardiac arrest survival; however, lack of willingness or community training lead to low bystander CPR rates. Virtual Reality (VR) Cardiopulmonary Resuscitation (CPR) training among high-school students is an innovative method to train bystander CPR skills. VR is well received by "technology natives" inherent among high school students and induces a greater sense of presence and agency compared to office-based CPR training. We describe a pilot trial with high school students using a near-peer mentoring framework using a single- player VR CPR training software (CBS, TetraSignum, Seoul, KR) in which both students collaboratively coach each other while performing in-VR CPR. Our pilot program recruited 3 pairs (n = 6) high school students during a local summer camp. During each 1.5-hour session, each pair learned about CPR and basic life support through a VR avatar either in-VR or displayed on a TV screen. The in-VR student practiced on the manikin while the other student could take notes on paper. Then each student was assessed on their CPR skills in-VR on a cardiac arrest avatar superimposed onto a real QCPR manikin, coached by the other student who could visualize CPR quality projected on the TV screen. The students then switched roles and debriefed about their experience. Overall, the students universally performed well and appreciated the collaborative nature of the learning experience. Further study is needed to explore barriers and enablers to implementation of VR CPR training at the high school level.

Pediatric emergency department shift experiences and moods: An exploratory sequential mixed-methods study.

OBJECTIVE: The objective was to investigate the impact of affective, social, behavioral, and cognitive factors on pediatric emergency department (PED) provider mood changes during clinical shifts, with the introduction of a novel on-shift measure. METHODS: The nominal group technique was used to generate the ED experience survey (EDES), encompassing factors that may influence PED provider mood. Providers were alerted via experience sampling method to complete the EDES and positive and negative affect schedule at randomly generated times. Analyses were conducted using multilevel modeling of moods within shifts within persons. RESULTS: Measures were completed 221 times during 137 shifts by 52 PED providers. Positive mood tended to increase with higher self-rated capacity to deal with challenging patient situations (p < 0.001). Having to repeat patient assessments was negatively associated with positive mood during the beginning, but not rest of shift (p = 0.01). Changes in positive mood varied across provider groups (p < 0.001). Negative mood tended to decrease with higher self-rated quality of interactions with patients/families (p < 0.001). Needing a restroom break during any time on duty was associated with negative mood (p < 0.001). Furthermore, negative mood was associated with the need to process emotions during the shift beginning (p = 0.01). Finally, not knowing about patients' outcomes was associated with negative mood during the shift end (p < 0.001). CONCLUSIONS: PED providers' mood during shifts are impacted by ED-specific factors spanning physical, social, behavioral, affective, and cognitive features. Future research may explore potential entry points for mitigation of clinician stress to support provider well-being and ultimately improve patient care.

Capillary blood gas in infants with bronchiolitis: Can end-tidal capnography replace it?

OBJECTIVES: To explore the predictive ability of capillary blood gas (CBG) pCO2 for respiratory decompensation in infants aged ≤6 months with bronchiolitis admitted from the emergency department; to determine whether end-tidal CO2 (etCO2) capnography can serve as a less invasive substitute for CBG pCO2. STUDY DESIGN: This was a prospective cohort study of previously healthy infants aged ≤6 months admitted for bronchiolitis from the emergency department (ED). Initial CBG pCO2 and etCO2 capnography were obtained in the ED prior to inpatient admission. Simple logistic regression modeling was used to examine the associations of CBG pCO2 and etCO2 capnography with respiratory decompensation. Pearson's correlation measured the relationship between CBG pCO2 and etCO2 capnography. RESULTS: Of 134 patients, 61 had respiratory decompensation. There was a significant association between CBG pCO2 and respiratory decompensation (OR = 1.07, p = 0.003), even after outlying values were excluded (OR = 1.06, p = 0.005). End tidal CO2 capnography was not significantly associated with decompensation (OR = 1.02, p = 0.17), even after outlying values were excluded (OR = 1.02, p = 0.24). There was a moderate correlation between etCO2 capnography and CBG pCO2 (r = 0.39, p < 0.001). CONCLUSION: In infants with bronchiolitis, CBG pCO2 provides an objective measure for predicting respiratory decompensation, and a single etCO2 measurement should not replace its use.

Assessing the Utility of Urine Testing in Febrile Infants 2 to 12 Months of Age With Bronchiolitis.

BACKGROUND: The utility of testing for urinary tract infection (UTI) in febrile infants with bronchiolitis is indeterminate. OBJECTIVE: The objective of this study was to investigate if the incidence of UTIs in febrile infants 2 to 12 months of age with bronchiolitis is higher than the presumed incidence of asymptomatic bacteriuria and determine risk factors associated with UTIs in this population. METHODS: This prospective multicenter cross-sectional study was conducted in the emergency departments of 6 children's hospitals between November 2011 and June 2015. We obtained a convenience sample of febrile infants with bronchiolitis 2 to 12 months of age who were tested for UTI. Patient characteristics analyzed included age, maximum temperature, duration of fever, ethnicity, sex, and circumcision status. RESULTS: A total of 442 patients (including 86 from a previously published pilot study) were enrolled. Mean age was 5.5 months, 65.2% were Latino, 50.9% were male, and 27.6% of male infants were circumcised. Urinary tract infections were found in 33 patients (7.69%, binomial; 95% confidence interval [CI], 5.19%-10.33%). Urinary tract infections were not related to age, height of temperature, duration of fever, or ethnicity. Uncircumcised males were significantly more likely to have UTIs than circumcised males (7.64% vs 0%, P = 0.03). Odds ratios (ORs) were lower for circumcised males but not uncircumcised males when compared with females (OR, 0.12; CI, 0.0-0.71; P = 0.01 vs OR, 0.77; CI, 0.33-1.74; P = 0.64). CONCLUSIONS: Febrile infants 2 to 12 months of age with bronchiolitis have a clinically significant incidence of UTI, suggesting that UTI evaluation should be considered in these patients.

Pediatric Emergency Department Responses to COVID-19: Transitioning From Surge Preparation to Regional Support.

In the midst of a global pandemic, hospitals around the world are working to meet the demand for patients ill with the 2019 coronavirus disease (COVID-19) caused by the novel coronavirus first identified in Wuhan, China. As the crisis unfolds, several countries have reported lower numbers as well as less morbidity and mortality for pediatric patients. Thus, pediatric centers find themselves pivoting from preparing for a patient surge to finding ways to support the regional response for adults. This study describes the response from 2 West Coast freestanding academic children's hospitals that were among the first cities in the United States impacted during this pandemic.

Surge activation by the emergency department for COVID-19.

In March 2020, the American College of Emergency Physicians (ACEP) published a national strategic plan for COVID-19, which provides general guidelines yet leaves logistical details for institutions to determine. Key capabilities from this plan provided a crucial foundation for a 16-day Emergency Department (ED) surge planning process at one pediatric institution. This paper describes critical milestones and lessons learned during this brief period, including derivation of criteria for ED surge activation, a full-scale surge drill, and the resultant ED surge protocol. The framework of real-time evaluation was used throughout the planning process and involved constant and iterative synthesis of real-time feedback from multidisciplinary stakeholders for responsive decision-making. Ultimately, the objective of this paper is to provide timely and readily actionable information to other institutions seeking guidance to apply the ACEP strategic plan for COVID-19.

Defining "Swarming" as a New Model to Optimize Efficiency and Education in an Academic Emergency Department.

BACKGROUND: Academic emergency medicine is a constant balance between efficiency and education. We developed a new model called swarming, where the bedside nurse, resident, and attending/fellow simultaneously evaluate the patient, including initial vital signs, bedside triage, focused history and physical examination, and discussion of the treatment plan, thus creating a shared mental model. OBJECTIVES: To combine perceptions from trainee physicians, supervising physicians, nurses, and families with in vivo measurements of emergency department swarms to better conceptualize the swarming model. METHODS: This mixed methods study was conducted using a convergent design. Qualitative data from focus groups with nurses, residents, and attendings/fellows were analyzed using directed content analysis. Swarming encounters were observed in real time; durations of key aspects and family satisfaction scores were analyzed using descriptive statistics. The qualitative and quantitative findings were integrated a posteriori. RESULTS: From the focus group data, 54 unique codes were identified, which were grouped together into five larger themes. From 39 swarms, mean (±SD) time (minutes) spent in patient rooms: nurses = 6.8 (±3.0), residents = 10.4 (±4.1), and attendings/fellows = 9.4 (±4.3). Electronic documentation was included in 67% of swarms, and 39% included orders initiated at the bedside. Mean (±SD) family satisfaction was 4.8 (±0.7; Likert scale 1-5). CONCLUSIONS: Swarming is currently implemented with significant variability but results in high provider and family satisfaction. There is also consensus among physicians that swarming improves trainee education in the emergency setting. The benefits and barriers to swarming are underscored by the unpredictable nature of the ED and the observed variability in implementation. Our findings provide a critical foundation for our efforts to refine, standardize, and appraise our swarming model.

Teaching Splinting Techniques Using a Just-in-Time Training Instructional Video.

OBJECTIVE: Splinting is a multistep procedure that is seldom performed by primary care physicians. Just-in-time training (JITT) is an emerging teaching modality and can be an invaluable asset for infrequently performed procedures or in locations where teaching resources and trained professionals are limited. Our objective was to determine the utility of JITT for teaching medical students the short-arm (SA) volar splinting technique. METHODS: This was a prospective randomized controlled pilot study. An instructional video on SA volar splinting was produced. Students viewed the video or had access to standard medical textbooks (control group) immediately before applying an SA volar splint. The students were assessed for the quality of the splint via a standard 6-point skills checklist. The times required for presplinting preparation and for completion of the splint were also measured. RESULTS: Just-in-time training group students scored higher on the splint checklist (mean [SD], 5.45 [1.06]; 95% confidence interval [CI], 4.99-5.92 vs mean [SD], 1.58 [1.12]; 95% CI, 1.04-2.12; P < 0.0001), had higher pass rates (73%; 95% CI, 53%-93% vs 0%; P < 0.0001), and required less time (minutes) for presplinting preparation (mean [SD], 7.86 [2.45]; 95% CI, 6.78-8.94 vs mean [SD], 9.89 [0.46]; 95% CI, 9.67-10.12; P < 0.0001) compared with the control group. No difference was seen in the time required to complete a splint, successful or not. CONCLUSIONS: In comparison with reading standard textbooks, watching a brief JITT instructional video before splinting yielded faster learning times combined with more successful procedural skills. The use of a JITT instructional video may have potential applications, including globally, as an alternative resource for teaching and disseminating procedural skills, such as SA volar splinting.

Acute Rheumatic Fever: An Evidence-Based Approach To Diagnosis And Initial Management.

Acute rheumatic fever is an inflammatory reaction involving the joints, heart, and nervous system that occurs after a group A streptococcal infection. It typically presents as a febrile illness with clinical manifestations that could include arthritis, carditis, skin lesions, or abnormal movements. Of these, the cardiac manifestations of acute rheumatic fever are most concerning, as children may present in acute heart failure and may go on to develop valvular insufficiency or stenosis. Because this is a rare presentation to emergency departments in developed countries, it is crucial for clinicians to keep a broad differential when presented with clinical presentations suspicious for acute rheumatic fever. This issue focuses on the clinical evaluation and treatment of patients with acute rheumatic fever by offering a thorough review of the literature on diagnosis and recommendations on appropriate treatment.

A retrospective comparison of ketamine dosing regimens for pediatric procedural sedation.

OBJECTIVE: Ketamine is a dissociative agent often used in pediatric emergency departments for procedural sedation. Institutions commonly use either 1.5 mg/kg (k1.5) or 1 mg/kg (k1.0) as intravenous dosing. We sought to determine whether patients receiving k1.0 require more administered doses during sedation than patients receiving k1.5. Furthermore, we examined whether differences existed between k1.0 and k1.5 in the total dosage, total mg/kg, and time to recovery. PATIENTS AND METHODS: A retrospective chart review examining procedural sedations from July 2010 through December 2011 was performed for sedations using k1.0 or k1.5. Cohorts were compared on the basis of the number of doses, mg/kg administered, total dosage (mg), and adverse events. RESULTS: A total of 346 patients were included, with 159 patients in k1.0 and 187 patients in k1.5. No significant differences in demographics were observed between k1.0 and k1.5. Patients in k1.5 required fewer median doses of ketamine compared with k1.0 (1.0 vs. 2.0, P=0.02). k1.0 had a higher median overall mg/kg dosage (1.71 mg/kg) than k1.5 (1.60 mg/kg) (P<0.01). k1.5 showed a decrease in the number of sedations requiring a third dose of ketamine to complete sedation as compared with k1.0 (7.57 vs. 18.47%, P=0.002). No significant difference in adverse events was found between k1.0 and k1.5. CONCLUSION: Sedations using k1.5 require fewer doses, lower mg/kg administered, but a higher total dose than k1.0. No difference was found in the rate of adverse events between the groups. Our findings suggest that ketamine sedations can be completed safely with one dose when patients are initially dosed at 1.5 mg/kg.

An evidence-based approach to the management of hematuria in children in the emergency department.

Hematuria is defined as an abnormal number of red blood cells in urine. Even a tiny amount of blood (1 mL in 1000 mL of urine) is sufficient to make urine appear pink or red. In the pediatric population, the majority of etiologies are benign and often asymptomatic. However, hematuria may also be a sign of renal pathology, local infection, or systemic disease. Hematuria can be differentiated into 2 categories: macroscopic hematuria (visible to the naked eye) and microscopic hematuria (> 5 red blood cells/high-powered field on urinalysis). This review will outline the current literature regarding evaluation and management of pediatric patients who present to the emergency department with hematuria. Obtaining a thorough history and the appropriate diagnostic tests will be discussed in depth.

Cryotherapeutic topical analgesics for pediatric intravenous catheter placement: ice versus vapocoolant spray.

OBJECTIVES: Intravenous catheter placement is one of the most common sources of pain for children in inpatient settings. We sought to compare the efficacy of 2 cryotherapeutic treatments for this procedure: vapocoolant spray versus topical ice pack. METHODS: We prospectively enrolled 95 patients, aged 9 to 18 years, in a pediatric emergency department who required intravenous (IV) catheters as part of their treatment. Subjects were randomly assigned to receive vapocoolant spray or topical ice pack for 3 minutes, before IV catheter placement. Subjects completed visual analog scale (VAS) scores for 3 time points: baseline, pretreatment with ice or spray, and IV insertion. The principal investigator and 2 physicians viewing video recordings of the procedure also completed VAS scores for observed pain levels. Visual analog scale scores were compared using the Wilcoxon rank sum test. RESULTS: Although median VAS scores were similar, the change in VAS from baseline was of greater magnitude in the Painease group, indicating that it may be more effective. More subjects in the Painease group (76%) felt their treatment worked well, compared with 49% in the ice group. Physician-assigned VAS scores were lower and less variable than those of subjects. Most IV insertions were successful (83%). CONCLUSIONS: Vapocoolant spray may be more effective than ice as an analgesic for IV insertion. Subjects were more satisfied with vapocoolant spray. Neither agent caused a decrease in successful IV insertion rates.

Dehydration treatment practices among pediatrics-trained and non-pediatrics trained emergency physicians.

OBJECTIVES: We sought to survey emergency physicians in the United States regarding the management of pediatric dehydration secondary to acute gastroenteritis. We hypothesized that responses from physicians with dedicated pediatric training (PT), that is, board certification in pediatrics or pediatric emergency medicine, would differ from responses of physicians with no dedicated pediatric training (non-PT). METHODS: An anonymous survey was mailed to randomly selected members of the American College of Emergency Physicians and sent electronically to enrollees of Brown University pediatric emergency medicine listserv. The survey consisted of 17 multiple-choice questions based on a clinical scenario depicting a 2-year-old with acute gastroenteritis and moderate dehydration. Questions asked related to treatment preferences, practice setting, and training information. RESULTS: One thousand sixty-nine surveys were received: 997 surveys were used for data analysis, including 269 PT physicians and 721 non-PT physicians. Seventy-nine percent of PT physicians correctly classified the scenario patient as moderately dehydrated versus 71% of non-PT physicians (P = 0.063). Among those who correctly classified the patient, 121 PT physicians (58%) and 350 non-PT physicians (68%) would initially hydrate the patient with intravenous fluids. Pediatrics-trained physicians were more likely to initially choose oral or nasogastric hydration compared with non-PT physicians (P = 0.0127). Pediatrics-trained physicians were less likely to perform laboratory testing compared with the non-PT group (n = 92, 45%, vs n = 337, 66%; P < 0.0001). CONCLUSIONS: Contrary to established recommendations for the management of moderately dehydrated children, significantly more PT physicians, compared with non-PT physicians, follow established guidelines.

Does using heat with eutectic mixture of local anesthetic cream shorten analgesic onset time? A randomized, placebo-controlled trial.

STUDY OBJECTIVES: We determine whether the addition of heat to topical eutectic mixture of local anesthetic (EMLA) cream shortens the onset time to effective analgesia. We hypothesized that applying EMLA cream for 20 minutes with an external heat pack would be as effective as the standard 60-minute application time. METHODS: In this prospective, double-blind study using adult volunteers, research subjects were randomized into groups undergoing either 20 minutes or 60 minutes of EMLA cream application time. Each research subject underwent randomized cream application over both hands and wrists in the following manner: EMLA cream with heat, EMLA cream without heat, placebo with heat, and placebo without heat. Research subjects then underwent a single attempt at intravenous catheterization over each of the 4 sites and scored the degree of pain using a 100-mm visual analog scale. RESULTS: Seventy-six research subjects were enrolled: 39 were randomized to the 20-minute group, and 37 were randomized to the 60-minute group. EMLA cream applied for 20 minutes with heat (adjusted mean visual analog scale score of 31.9 mm) provided statistically and clinically significantly greater analgesia compared with that seen in the placebo groups with or without heat (46.6 and 46.1 mm, respectively), with estimated differences of -14.6 (95% confidence interval [CI] -21.2 to -8.1) and -14.1 (95% CI -20.8 to -7.3), respectively. However, applying EMLA cream for 60 minutes without heat (16.6 mm) provided better analgesia compared with that seen after 20 minutes of EMLA cream with heat (31.9 mm; estimated difference of -15.4 [95% CI -25.1 to -5.6]). CONCLUSION: Applying EMLA cream for 20 minutes with heat provides intermediate analgesia for intravenous catheter placement, although 60 minutes of application time remains superior.