Driving Time to Trauma Centers for Children Living in Wisconsin.

INTRODUCTION: Trauma is the number 1 cause of death among children. Shorter distance to definitive trauma care has been correlated with better clinical outcomes. There are only a small number of pediatric trauma centers (PTC) designated by the American College of Surgeons, and the resources available to treat injured children at non-PTCs are limited. To guide resource allocation and advocacy efforts for pediatric trauma care in Wisconsin, we determined the precise distance to trauma centers for all children living in the state. METHODS: The 2010 US Census data was used to determine ZIP-centroid geolocation. The Wisconsin Department of Health Services trauma classification database was used to identify trauma facilities in Wisconsin. SAS routines invoking the Google Maps application programming interface were used to calculate the driving distance to each of the trauma facilities. We quantified the percentage of children living within 30- and 60-minute driving distances of level I-IV trauma centers. RESULTS: Just 31.3% of Wisconsin children live within a 30-minute drive of a level I PTC; 32.7% live within 30 minutes of a level II center; 81.3% within 30 minutes of a level III center; and 74.6% within 30 minutes of a level IV center. CONCLUSION: Two-thirds of children in Wisconsin live beyond a 30-minute driving distance of a level I PTC, but most children live within 30 minutes of level III and IV trauma centers. As the closest hospitals for most children, smaller trauma centers should be adequately resourced to provide pediatric trauma care.

Factors Affecting Family Presence During Fracture Reduction in the Pediatric Emergency Department.

INTRODUCTION: Asking family members to leave during invasive procedures has historically been common practice; however, evidence-based recommendations have altered the trend of family presence during pediatric procedures. The aim of this study was to determine factors related to family members' choice to be present or absent during fracture reductions in a pediatric emergency department (ED), and their satisfaction with that choice. METHODS: We administered role-specific, anonymous surveys to a convenience sample of patients' family members in the ED of a Level I pediatric trauma center. All family members were given a choice of where to be during the procedure. RESULTS: Twenty-five family members of 18 patients completed surveys. Seventeen family members chose to stay in the room. Family member satisfaction with their decision to be inside or outside the room during the procedure (median = very satisfied) was almost uniformly high and not associated with any of the following variables: previous presence during a medical procedure; provider-reported procedure difficulty, or anxiety levels. Family member perception of procedure success (median = extremely well) was also high and not associated with other variables. Location during the procedure was associated with a desire to be in the same location in the future (Fisher's exact test, p=0.001). Common themes found among family members' reasons for their location decisions and satisfaction levels were a desire to support the patient, high staff competence, and their right as parents to choose their location. CONCLUSION: Family members self-select their location during their child's fracture reduction to high levels of satisfaction, and they considered the ability to choose their location as important.

Secure Provider-to-Provider Communication With Electronic Health Record Messaging: An Educational Outreach Study.

INTRODUCTION: With increasing electronic health record (EHR) use, providers are talking less with one another. Now, many rely on EHRs, informal emails, or texts, introducing fragmentation and new data security challenges with new communication strategies. We aimed to examine the impact of a physician champion educational outreach intervention to promote electronic provider-to-provider communication in a large academic multispecialty group. METHODS: Physician champions provided educational outreach to 16 academic departments, using 10-minute case-based presentations. Online surveys assessed communication preferences and practices. Electronic health record queries counted EHR messaging use before and after intervention. Descriptive statistics compared responses by specialty (z-test). Paired responses with pre-post data were compared using chi-square tests. Time series analysis assessed EHR messaging rates before intervention versus after intervention. RESULTS: Five hundred seventeen providers responded to the postoutreach survey. Eighty-six percent were familiar with EHR messaging tool and 78% knew how to use it after intervention. Among practitioner groups, Family Medicine preferred EHR messaging the most (62%). Groups who declined outreach least preferred it (26%). Among 88 respondents with paired pre-post intervention surveys, familiarity rose (79-96%), and self-reported use increased (66-88%). CONCLUSIONS: Physician champion educational outreach increased the use of the secure provider-to-provider EHR messaging tool.

Using Chief Complaint in Addition to Diagnosis Codes to Identify Falls in the Emergency Department.

OBJECTIVES: To compare incidence of falls in an emergency department (ED) cohort using a traditional International Classification of Diseases, Ninth Revision (ICD-9) code-based scheme and an expanded definition that included chief complaint information and to examine the clinical characteristics of visits "missed" in the ICD-9-based scheme. DESIGN: Retrospective electronic record review. SETTING: Academic medical center ED. PARTICIPANTS: Individuals aged 65 and older seen in the ED between January 1, 2013, and September 30, 2015. MEASUREMENTS: Two fall definitions were applied (individually and together) to the cohort: an ICD-9-based definition and a chief complaint definition. Admission rates and 30-day mortality (per encounter) were measured for each definition. RESULTS: Twenty-three thousand eight hundred eighty older adult visits occurred during the study period. Using the most-inclusive definition (ICD-9 code or chief complaint indicating a fall), 4,363 visits (18%) were fall related. Of these visits, 3,506 (80%) met the ICD-9 definition for a fall-related visit, and 2,664 (61%) met the chief complaint definition. Of visits meeting the chief complaint definition, 857 (19.6%) were missed when applying the ICD-9 definition alone. Encounters missed using the ICD-9 definition were less likely to lead to an admission (42.9%, 95% confidence interval (CI) = 39.7-46.3%) than those identified (54.4%, 95% CI = 52.7-56.0%). CONCLUSION: Identifying individuals in the ED who have fallen based on diagnosis codes underestimates the true burden of falls. Individuals missed according to the code-based definition were less likely to have been admitted than those who were captured. These findings call attention to the value of using chief complaint information to identify individuals who have fallen in the ED-for research, clinical care, or policy reasons.

A rare case of posterior interosseous nerve palsy associated with radial head fracture.

BACKGROUND: Radial head fractures are the most common fractures occurring about the elbow in adults, but there have been few reported cases of associated nerve injury. The little-known posterior interosseous nerve travels in close proximity to the radial head and is particularly susceptible to injury. OBJECTIVES: The objectives of this case report include raising awareness of the possibility of posterior interosseous nerve palsy after radial head fracture and reviewing the clinical assessment of the posterior interosseous nerve to exclude occult injury. CASE REPORT: Here we report a case of a 21-year-old man who developed a posterior interosseous nerve palsy after a fracture of the radial head sustained during a wrestling match. He also sustained frostbite to the extremity due to overaggressive icing of the injury. CONCLUSIONS: Physicians should screen patients with radial head fractures for associated nerve injury. A thorough neurovascular examination with attention to the motor innervation patterns in the hand and wrist will help identify posterior interosseous nerve involvement. Careful discharge instructions will help prevent iatrogenic frostbite from overaggressive icing of injuries.

A randomized clinical trial of ibuprofen versus acetaminophen with codeine for acute pediatric arm fracture pain.

STUDY OBJECTIVE: We compare the treatment of pain in children with arm fractures by ibuprofen 10 mg/kg versus acetaminophen with codeine 1 mg/kg/dose (codeine component). METHODS: This was a randomized, double-blind, clinical trial of children during the first 3 days after discharge from the emergency department (ED). The primary outcome was failure of the oral study medication, defined as use of the rescue medication. Pain medication use, pain scores, functional outcomes, adverse effects, and satisfaction were also assessed. RESULTS: Three hundred thirty-six children were randomized to treatment, 169 to ibuprofen and 167 to acetaminophen with codeine; 244 patients were analyzed. Both groups used a median of 4 doses (interquartile range 2, 6.5). The proportion of treatment failures for ibuprofen (20.3%) was lower than for acetaminophen with codeine (31.0%), though not statistically significant (difference=10.7%; 95% confidence interval -0.2 to 21.6). The proportion of children who had any function (play, sleep, eating, school) affected by pain when pain was analyzed by day after injury was significantly lower for the ibuprofen group. Significantly more children receiving acetaminophen with codeine reported adverse effects and did not want to use it for future fractures. CONCLUSION: Ibuprofen was at least as effective as acetaminophen with codeine for outpatient analgesia for children with arm fractures. There was no significant difference in analgesic failure or pain scores, but children receiving ibuprofen had better functional outcomes. Children receiving ibuprofen had significantly fewer adverse effects, and both children and parents were more satisfied with ibuprofen. Ibuprofen is preferable to acetaminophen with codeine for outpatient treatment of children with uncomplicated arm fractures.

Effect of volume resuscitation on regional perfusion in dehydrated pediatric patients as measured by two-site near-infrared spectroscopy.

OBJECTIVE: The aim of this study was to measure the change of cerebral and somatic regional oxygen saturation (rSO2) using near-infrared spectroscopic (NIRS) monitoring during volume resuscitation of dehydrated children. METHODS: This prospective, observational study enrolled 17 moderately dehydrated children presenting to the emergency department in a tertiary care pediatric hospital. Pulse oximetry and 2-site rSO2 using forehead and flank NIRS probes were monitored continuously during intravenous rehydration. RESULTS: Prehydration and posthydration data were summarized as mean (SD) and analyzed by paired 2-sided Student t test. Significance was defined as a P < 0.05. Pulse oximetry and cerebral rSO2 remained unchanged throughout rehydration. The somatic rSO2 increased from 79% (13) to 87% (9) (P < 0.01) with rehydration, and the somatic-cerebral rSO2 difference increased from 5% (7) to 13% (6) (P < 0.001). The high-volume rehydration group (33-40 mL/kg) showed a greater increase in somatic rSO2 with rehydration when compared with the low-volume rehydration group (20 mL/kg). The measured increase in somatic rSO2 was greatest in children weighing less than 15 kg. CONCLUSIONS: In children with acute dehydration, cerebral rSO2 is preserved in moderate dehydration. Somatic tissue beds show an increase in rSO2 by NIRS oximetry with rehydration. Two-site NIRS monitoring is a continuous, noninvasive quantitative method for early detection of regional hypoperfusion in dehydrated children.

Vomiting of liquid corticosteroids in children with asthma.

BACKGROUND: Oral corticosteroids are an essential part of the management of children with acute asthma exacerbations. Vomiting is a frequently cited problem attributed to oral corticosteroids. A new formulation of prednisolone, Orapred, claims to have improved palatability that may decrease the incidence of vomiting. OBJECTIVE: To compare the incidence of vomiting and taste between patients who are given the generic preparation of prednisolone with those given Orapred. DESIGN/METHODS: A randomized, double blind clinical trial was conducted at a tertiary care children s hospital emergency department. Children age 2 to 10 years presenting with acute asthma exacerbation were eligible. Patients with allergy to prednisolone, corticosteroid use within 2 weeks, history of vomiting in the last 24 hours, requirement for vascular access, and preference for other forms of corticosteroid were excluded. Enrolled patients were randomized and given either generic prednisolone (15 mg/5 ml) or Orapred (15 mg/5 ml). In children 6 years or older, a taste score was obtained using a 5 point hedonic face scale (1 = bad to 5 = great). After the administration, patients were observed for 30 minutes for vomiting. The Mann-Whitney U test was used to compare the median taste score between the two study groups. Relative risk (RR) of vomiting was calculated. Other confidence intervals were calculated when appropriate. RESULTS: During the study period, 211 eligible children were enrolled, of whom 23 were excluded. Of the remaining 188 subjects, 96 received generic prednisolone and 92 received Orapred. All baseline characteristics were similar in both groups. In the generic prednisolone group, 17 (17.7%) children vomited compared with 5 (5.4%) in the Orapred group (RR = 3.26, 95% CI, 1.25, 8.47). Taste scores were obtained from 18 children in the generic prednisolone group and from 19 children in the Orapred group. The median taste score was 2 for the generic prednisolone group and 4 for the Orapred group (Delta = -2.0, 95% CI, -3.0, -1.0) (P = 0.0001). CONCLUSIONS: In our study population, Orapred was associated with a significant less incidence of vomiting and better taste score compared to the generic prednisolone.

Outpatient pediatric pain management practices for fractures.

OBJECTIVES: Describe the pattern of utilization and effectiveness of outpatient fracture pain medication. METHODS: A cross-sectional survey of caregivers of children with an isolated extremity fracture at a hospital-based pediatric orthopedic clinic during initial follow-up. RESULTS: Surveys were completed by 98 (79.2%) of 125 caregivers. Mean age of children was 9 years (range, 1-18 years). Fracture sites include arm (36%), wrist (24%), hand (6%), leg (14%), ankle (9%), and foot (6%). Pain was reported "worst" at the time of injury in 45.3% patients (95% confidence interval [CI], 35.0%-55.8%) and in the first 48 hours of injury in 30.5% patients (95% CI, 21.5%-40.8%). The most commonly used medications were ibuprofen 43.5% (95% CI, 34.4%-52.5%) and acetaminophen with codeine 26.1% (95% CI, 18.1%-34.1%). Mean duration of medication use was 3.2 days (95% CI, 2.8-3.6 days). The mean duration of functional limitations included 4.2 days (95% CI, 2.8-5.5 days) for playing, 2.6 days (95% CI, 1.7-3.4 days) for performing at school, 2.4 days (95% CI, 1.8-3.0 days) for sleeping, and 2.0 days (95% CI, 1.0-3.0 days) for eating. Mean days of work missed by caregivers was 1.6 (95% CI, 1.1-2.0 days), and days of school missed by children was 2.0 (95% CI, 1.6-2.3 days). Significantly more children with lower extremity fractures had functional limitation (P < 0.05). CONCLUSION: Most children with fractures have the "worst" pain in the first 48 hours after injury and used analgesia for 3 days after injury. There are noteworthy functional limitations for both children and their caregivers. Ibuprofen and acetaminophen with codeine are the analgesics most commonly used, with no clear superiority.

Prehospital pain management: a comparison of providers' perceptions and practices.

OBJECTIVE: To assess the knowledge of emergency medical technicians-paramedics (EMT-Ps) and compare their practice perceptions with actual pain management interventions in adults and pediatric patients (adolescents and children) with chest pain (CP), extremity injuries, or burns. METHODS: This study included a cross-sectional survey of EMT-Ps and review of the emergency medical services (EMS) system patient care database. EMT-Ps were surveyed for: 1) knowledge of pain treatment protocol; 2) estimated number of CP, extremity injury, or burn encounters and the frequency of morphine administration; and 3) barriers to providing morphine. Data on patients transported with any above conditions and those who received morphine were abstracted from the EMS patient care database. Data were analyzed using descriptive statistics, and 95% confidence intervals (CIs) were calculated. RESULTS: Of 202 EMT-Ps, 155 (77%) completed the survey. Eighty-two percent reported knowledge of pain treatment protocol for both adults and pediatric patients. For adults, EMT-Ps estimated they administered morphine to 37% with CP (95% CI 35, 40), 24% with extremity injuries (95% CI 17, 30), and 89% with burns (95% CI 52, 99). In children and adolescents, inability to assess pain (93%) was the most common reason for withholding morphine. According to the EMS database, 5% of adults with CP (95% CI 4, 5), 12% extremity injuries (95% CI 8, 15), and 14% burns (95% CI 8, 20) received morphine. In children and adolescents, 3% with extremity injuries (95% CI 1, 5) and 9% with burns (95% CI 0, 26) received morphine. Pain score was documented in 67.0% of adult patients, compared with only 4.0% in pediatric patients (Delta = 63.0%, 95% CI: 60, 65). CONCLUSIONS: Significant disparity exists between EMT-Ps' perceptions of acute pain assessment and the frequency of providing analgesia and their actual practice. Children and adolescents had less documentation of pain assessment and received less analgesic interventions compared with adults. Inability to assess pain may be an important barrier to the provision of analgesia.

The anesthetic effectiveness of lidocaine-adrenaline-tetracaine gel on finger lacerations.

OBJECTIVES: To determine the effectiveness of lidocaine-adrenaline-tetracaine (LAT) in providing adequate anesthesia for the repair of finger lacerations and to monitor the risk of digital ischemia following application of LAT gel to finger lacerations. METHODS: A prospective case series. Children aged 5 to 18 years with a simple finger laceration-requiring repair were eligible for enrollment. The primary outcome measure was LAT success/failure. Failure was defined as any sharp sensation reported by the patient either before or during suturing. Enrolled patients had LAT gel applied to their laceration for 45 minutes, followed by an examination for signs of digital ischemia and standard laceration repair. Infiltration anesthesia (local subcutaneous injection/digital block) was provided for all LAT failures. Patients were followed up by phone within 3 to 5 days from discharge. RESULTS: Sixty-seven patients were analyzed in the study. The mean age was 11.9 years. Forty-four (65.7%) of 67 patients were male and 46 (68.7%) were white. Locations of the lacerations were equally distributed on the dorsal and ventral surfaces. The overall LAT success rate was 53.7% (95% confidence interval [CI], 41.1% to 66.0%; 36/67). The success rate for dorsal surface lacerations was 68.6% (95% CI, 50.7% to 83.1%; 24/35) versus 37.5% (95% CI, 21.1% to 56.3%; 12/32) for ventral surface lacerations. The difference in success rates between dorsal and ventral surface lacerations was significant (Delta 31.1% [95% CI, 8.3% to 53.8%]). There were no differences in success rates for age, sex, or race. No signs of digital ischemia were noted in any of the 67 cases (0% [95% CI, 0.0% to 5.4%]). CONCLUSIONS: LAT gel appears to be a safe and effective means of providing anesthesia for the repair of simple finger lacerations in children. It was most effective on the dorsal surface of the finger.

Morbidity following central compartment reoperation for recurrent or persistent thyroid cancer.

OBJECTIVE: To determine the incidence of recurrent laryngeal nerve injury and hypoparathyroidism, we reviewed our experience with central compartment reoperation. DESIGN: Patients underwent preoperative ultrasonography and magnetic resonance imaging of the neck. Ultrasound-guided fine-needle aspiration biopsy was performed and demonstrated evidence of tumor in 15 patients. At the time of surgery, hook wire electrodes were placed endoscopically into 1 or both vocal cords to monitor the integrity of the recurrent laryngeal nerve. PATIENTS: The study population comprised 20 patients who had undergone reoperative central compartment dissections between the years 1997 and 2001. There were 15 women and 5 men whose mean age was 49.4 years. All of the patients had prior total or subtotal thyroidectomy, and 4 patients had prior neck dissections. A primary thyroid cancer recurrence in the thyroid bed was present in 7 patients, and the remainder of the patients had cytological evidence of paratracheal or mediastinal metastases. A single patient had evidence of distant metastases involving the lung. MAIN OUTCOME MEASURE: Short- and long-term postoperative morbidity. RESULTS: Of the 20 patients, 18 had histologic evidence of metastases to the paratracheal lymph nodes, whereas 8 patients had metastases involving the anterior mediastinal lymph nodes. The mean number of lymph nodes removed was 6.5, and the mean number of positive lymph nodes was 4.7. None of the patients with normal preoperative laryngeal function had postoperative recurrent laryngeal nerve paresis or paralysis. There were 18 patients with normal preoperative parathyroid function. Four patients developed transient postoperative hypocalcemia. All 4 patients with transient postoperative hypocalcemia are currently eucalcemic. A single patient continues to receive calcium and calcitriol supplementation 1 month following her third central compartment dissection for recurrent thyroid cancer. CONCLUSIONS: Reoperation for recurrent or persistent thyroid cancer presents a significant challenge. However, intraoperative recurrent laryngeal nerve monitoring and preservation of the vascular pedicle of the parathyroid glands has reduced the morbidity of reoperative central compartment dissections to acceptable levels. Revision surgery in the central compartment of the neck is compatible with successful eradication of recurrent thyroid cancers and acceptable morbidity.

Analgesia for children with acute abdominal pain: a survey of pediatric emergency physicians and pediatric surgeons.

OBJECTIVE: To evaluate the current opinion and practice of pediatric emergency medicine physicians (PEM) and pediatric surgeons (PS) on the use of opioid analgesia in children with acute abdominal pain during their evaluation in the emergency department. METHODS: All members of the American Academy of Pediatrics in the Section of Emergency Medicine and the American Pediatric Surgeons Association were mailed a copy of the survey. Inclusion criteria were board-eligible or -certified PEM, or PS certified by American Board of Surgery or Royal College of Surgeons currently in practice whose patient population includes children. Information on primary patient population, years in practice, practice setting, willingness to provide analgesia for acute nontraumatic abdominal pain in children, and the factors influencing their decision were requested. Data were analyzed with the Student t test and chi(2) analysis. RESULTS: Of 1441 surveys sent, 54 were returned because of incorrect addresses. Of the 1387 presumed received, 702 completed surveys were returned with a response rate of 51%. However, of those who responded, 574 (82%) respondents met our inclusion criteria, and 385 (67%) were PEM and 189 (33%) were PS. Compared with PEM, more PS had >10 years of work experience and were in private practice. More PEM were willing to provide analgesia before definitive diagnosis. However, the overall willingness to provide analgesia was low in both groups. Among the physicians with <10 years of experience, there was no statistical difference between PEM and PS in willingness to provide analgesia. However, among the physicians with >10 years of experience, 61% of PS were less likely to provide analgesia compared with 38% of the PEM (Delta = 23%; 95% confidence interval 13%, 33%). Of the 74 PEM who made optional general comments, 64 (87%) cited disapproval by the PS as the main barrier in providing analgesia. CONCLUSIONS: The practice of providing analgesia for children with acute abdominal pain is divergent between PEM and PS. More experienced surgeons are less likely to provide analgesia for children with acute abdominal pain. The perceived disapproval of providing analgesia to children with acute abdominal pain by PS is a barrier influencing PEM practice.

A randomized clinical trial of analgesia in children with acute abdominal pain.

OBJECTIVE: To evaluate the effects of intravenous morphine on pain reduction, physical examination, and diagnostic accuracy in children with acute abdominal pain. METHODS: A randomized, double-blind, placebo-controlled clinical trial was conducted at an emergency department of a tertiary care children's hospital. Children aged 5-18 years with abdominal pain of < or =5 days' duration, pain score > or =5 on a 0-10 visual analog scale, and need for surgical evaluation were eligible. Following the initial assessment, patients were randomized to receive either 0.1 mg/kg morphine or an equal volume of saline. The pediatric emergency medicine physician and surgical consultant independently recorded the areas of tenderness to palpation and percussion, and their diagnoses before the study medication and 15 to 30 minutes later. RESULTS: Sixty patients were enrolled, and 29 received morphine and 31 received saline. The demographic characteristics between the two groups were similar. The median reduction of pain score between the two study groups was 2 (95% CI = 1 to 4; p = 0.002). There was no significant change in the areas of tenderness in both study groups. Children with surgical conditions had persistent tenderness to palpation and/or percussion. There was no significant change in the diagnostic accuracy between the study groups and between the physician groups. All patients requiring laparotomy were identified and no significant complication was noted in the morphine group. CONCLUSIONS: Intravenous morphine provides significant pain reduction to children with acute abdominal pain without adversely affecting the examination, and morphine does not affect the ability to identify children with surgical conditions.