Centiles for the shock index among injured children in the prehospital setting.

OBJECTIVE: The shock index (SI), the ratio of heart rate to systolic blood pressure, is a clinical tool for assessing injury severity. Age-adjusted SI models may improve predictive value for injured children in the out-of-hospital setting. We sought to characterize the proportion of children in the prehospital setting with an abnormal SI using established criteria, describe the age-based distribution of SI among injured children, and determine prehospital interventions by SI. METHODS: We performed a multi-agency retrospective cross-sectional study of children (<18 years) in the prehospital setting with a scene encounter for suspected trauma and transported to the hospital between 2018 and 2022 using the National Emergency Medical Services (EMS) Information System datasets. Our exposure of interest was the first calculated SI. We identified the proportion of children with an abnormal SI when using the SI, pediatric age-adjusted (SIPA); and the pediatric SI (PSI) criteria. We developed and internally validated an age-based distributional model for the SI using generalized additive models for location, scale, and shape to describe the age-based distribution of the SI as a centile or Z-score. We evaluated EMS interventions (basic airway interventions, advanced airway interventions, cardiac interventions, vascular access, intravenous fluids, and vasopressor use) in relation to both the SIPA, PSI, and distributional SI values. RESULTS: We analyzed 1,007,863 pediatric EMS trauma encounters (55.0% male, median age 13 years [IQR, 8-16 years]). The most common dispatch complaint was for traffic/transport related injury (32.9%). When using the PSI and SIPA, 13.1% and 16.3% were classified as having an abnormal SI, respectively. There were broad differences in the percentage of encounters classified as having an abnormal SI across the age range, varying from 5.1 to 22.8% for SIPA and 3.7-20.1% for PSI. The SIPA values ranged from the 75th to 95th centiles, while the PSI corresponded to an SI greater than the 90th centile, except in older children. The centile distribution for SI declined during early childhood and stabilized during adolescence and demonstrated a difference of <0.1% at cutoff values. An abnormal PSI, SIPA and higher SI centiles (>90th centile and >95th centiles) were associated with interventions related to basic and advanced airway management, cardiac procedures, vascular access, and provision of intravenous fluids occurred with greater frequency at higher SI centiles. Some procedures, including airway management and vascular access, had a smaller peak at lower (<10th) centiles. DISCUSSION: We describe the empiric distribution of the pediatric SI across the age range, which may overcome limitations of extant criteria in identifying patients with shock in the prehospital setting. Both high and low SI values were associated with important, potentially lifesaving EMS interventions. Future work may allow for more precise identification of children with significant injury using cutpoint analysis paired to outcome-based criteria. These may additionally be combined with other physiologic and mechanistic criteria to assist in triage decisions.

The association of prehospital systemic corticosteroids with emergency department and in-hospital outcomes for patients with asthma exacerbations.

BACKGROUND: Timely administration of systemic corticosteroids is a cornerstone of asthma exacerbation treatment, yet little is known regarding potential benefits of prehospital administration by emergency medical services (EMS) clinicians. We examined factors associated with prehospital corticosteroid administration with hospitalization and hospital length of stay (LOS). METHODS: We performed a retrospective study of EMS encounters for patients 2-50 years of age with suspected asthma exacerbation from a national data set. We evaluated factors associated with systemic corticosteroid administration using generalized estimating equations. We performed propensity matching based on service level, age, encounter duration, vital signs, and treatments to evaluate the association of prehospital corticosteroid administration with hospitalization and LOS using weighted logistic regression. We evaluated the association of prehospital corticosteroid administration with admission using Bayesian models. RESULTS: Of 15,834 encounters, 4731 (29.9%) received prehospital systemic corticosteroids. Administration of corticosteroids was associated with older age; sex; urbanicity; advanced life support provider; vital sign instability; increasing doses of albuterol; and provision of ipratropium bromide, magnesium, epinephrine, and supplementary oxygen. Within the matched sample, prehospital corticosteroids were not associated with hospitalization (odds ratio [OR] 0.86, 95% confidence interval [CI] 0.73-1.01) or LOS (multiplier 0.76, 95% CI 0.56-1.05). Administration of corticosteroids was associated with lower odds of admission and shorter LOS in longer EMS encounters (>34 min), lower admission odds in patients with documented wheezing, and shorter LOS among patients treated with albuterol. In a Bayesian model with noninformative priors, the OR for admission among encounters given corticosteroids was 0.86 (95% credible interval 0.77-0.96). CONCLUSIONS: Prehospital systemic corticosteroid administration was not associated with hospitalization or LOS in the overall cohort of asthma patients treated by EMS, though they had a lower probability of admission within Bayesian models. Improved outcomes were noted among subgroups of longer EMS encounters, documented wheezing, and receipt of albuterol.

Pediatric Utilization of Emergency Medical Services from Outpatient Offices and Urgent Care Centers.

OBJECTIVE: National efforts have highlighted the need for pediatric emergency readiness across all settings where children receive care. Outpatient offices and urgent care centers are frequent starting points for acutely injured and ill children, emphasizing the need to maintain pediatric readiness in these settings. We aimed to characterize emergency medical services (EMS) utilization from outpatient offices and urgent care centers to better understand pediatric readiness needs. METHODS: We performed a retrospective cross-sectional analysis of EMS encounters using the National Emergency Medical Services Information System, a nationally representative EMS registry (2019-2022). We included four years of EMS encounters of children (<18 years old) that originated from an outpatient office or urgent care center. We described characteristics, including patient demographics, prehospital clinician impression, therapies, and procedures performed. RESULTS: Of 179,854,336 EMS encounters during the study period, 164,387 pediatric encounters originated at an outpatient setting. Most EMS encounters originated from outpatient offices. Evening and weekend EMS encounters more frequently originated from urgent care centers. The most common impressions were respiratory distress (n = 60,716), systemic illness (n = 23,583), and psychiatric/behavioral health (n = 13,273). Ninety-four percent of EMS encounters resulted in transportation to a hospital. CONCLUSIONS: EMS encounters from outpatient settings most commonly originate from outpatient offices, relative to urgent care settings, where pediatric emergency readiness may be limited. It is important that outpatient settings and providers are ready for varied emergencies, including those occurring for a behavioral health concern, and that readiness guidelines are updated to address these needs.

Measures of Patient Acuity Among Children Encountered by Emergency Medical Services by the Child Opportunity Index.

Background: Children have differing utilization of emergency medical services (EMS) by socioeconomic status. We evaluated differences in prehospital care among children by the Child Opportunity Index (COI), the agreement between a child's COI at the scene and at home, and in-hospital outcomes for children by COI. Methods: We performed a retrospective study of pediatric (<18 years) scene encounters from approximately 2,000 United States EMS agencies from the 2021-2022 ESO Data Collaborative. We evaluated socioeconomic status using the multi-dimensional COI v2.0 at the scene. We described EMS interventions and in-hospital outcomes by COI categories using ordinal regression. We evaluated the agreement between the home and scene COI. Results: Data were available for 99.8% of pediatric scene runs, with 936,940 included EMS responses. Children from lower COI areas more frequently had a response occurring at home (62.9% in Very Low COI areas; 47.1% in Very High COI areas). Children from higher COI areas were more frequently not transported to the hospital (odds ratio [OR] 0.87, 95% confidence interval [CI] 0.86-0.87). Children in lower COI areas had lower use of physical (OR 1.23, 95% CI 1.13-1.33) and chemical (OR 1.41, 95% CI 1.29-1.55) restraints for behavioral health problems. Among injured children with elevated pain scores (≥7), analgesia was provided more frequently to children in higher COI areas (OR 1.73, 95% CI 1.65-1.81). The proportion of children in cardiac arrest was lowest from higher COI areas. Among 107,114 encounters with in-hospital data, the odds of hospitalization was higher among children from higher COI areas (OR 1.14, 95% CI 1.11-1.18) and was lower for in-hospital mortality (OR 0.75, 95% CI 0.65-0.85). Home and scene COI had a strong agreement (Kendall's W = 0.81). Conclusion: Patterns of EMS utilization among children with prehospital emergencies differ by COI. Some measures, such as for in-hospital mortality, occurred more frequently among children transported from Very Low COI areas, whereas others, such as admission, occurred more frequently among children from Very High COI areas. These findings have implications in EMS planning and in alternative out-of-hospital care models, including in regional placement of ambulance stations.

Association of midazolam route of administration and need for recurrent dosing among children with seizures cared for by emergency medical services.

OBJECTIVE: National guidelines in the United States recommend the intramuscular and intranasal routes for midazolam for the management of seizures in the prehospital setting. We evaluated the association of route of midazolam administration with the use of additional benzodiazepine doses for children with seizures cared for by emergency medical services (EMS). METHODS: We conducted a retrospective cohort study from a US multiagency EMS dataset for the years 2018-2022, including children transported to the hospital with a clinician impression of seizures, convulsions, or status epilepticus, and who received an initial correct weight-based dose of midazolam (.2 mg/kg intramuscular, .1 mg/kg intravenous, .2 mg/kg intranasal). We evaluated the association of route of initial midazolam administration with provision of additional benzodiazepine dose in logistic regression models adjusted for age, vital signs, pulse oximetry, level of consciousness, and time spent with the patient. RESULTS: We included 2923 encounters with patients who received an appropriate weight-based dose of midazolam for seizures (46.3% intramuscular, 21.8% intranasal, 31.9% intravenous). The median time to the first dose of midazolam from EMS arrival was similar between children who received intramuscular (7.3 min, interquartile range [IQR] = 4.6-12.5) and intranasal midazolam (7.8 min, IQR = 4.5-13.4) and longer for intravenous midazolam (13.1 min, IQR = 8.2-19.4). At least one additional dose of midazolam was given to 21.4%. In multivariable models, intranasal midazolam was associated with higher odds (odds ratio [OR] = 1.39, 95% confidence interval [CI] = 1.10-1.76) and intravenous midazolam was associated with similar odds (OR = 1.00, 95% CI = .80-1.26) of requiring additional doses of benzodiazepines relative to intramuscular midazolam. SIGNIFICANCE: Intranasal midazolam was associated with greater odds of repeated benzodiazepine dosing relative to initial intramuscular administration, but confounding factors could have affected this finding. Further study of the dosing and/or the prioritization of the intranasal route for pediatric seizures by EMS clinicians is warranted.

Predicting Serious Bacterial Infections Among Hypothermic Infants in the Emergency Department.

BACKGROUND: There is insufficient evidence to guide the initial evaluation of hypothermic infants. We aimed to evaluate risk factors for serious bacterial infections (SBI) among hypothermic infants presenting to the emergency department (ED). METHODS: We conducted a multicenter case-control study among hypothermic (rectal temperature <36.5°C) infants ≤90 days presenting to the ED who had a blood culture collected. Our outcome was SBI (bacteremia, bacterial meningitis, and/or urinary tract infection). We performed 1:2 matching. Historical, physical examination and laboratory covariables were determined based on the literature review from febrile and hypothermic infants and used logistic regression to identify candidate risk factors. RESULTS: Among 934 included infants, 57 (6.1%) had an SBI. In univariable analyses, the following were associated with SBI: age > 21 days, fever at home or in the ED, leukocytosis, elevated absolute neutrophil count, thrombocytosis, and abnormal urinalysis. Prematurity, respiratory distress, and hypothermia at home were negatively associated with SBI. The full multivariable model exhibited a c-index of 0.91 (95% confidence interval: 0.88-0.94). One variable (abnormal urinalysis) was selected for a reduced model, which had a c-index of 0.82 (95% confidence interval: 0.75-0.89). In a sensitivity analysis among hypothermic infants without fever (n = 22 with SBI among 116 infants), leukocytosis, absolute neutrophil count, and abnormal urinalysis were associated with SBI. CONCLUSIONS: Historical, examination, and laboratory data show potential as variables for risk stratification of hypothermic infants with concern for SBI. Larger studies are needed to definitively risk stratify this cohort, particularly for invasive bacterial infections.

Acute care utilization for ambulatory care-sensitive conditions among publicly insured children.

BACKGROUND: Although characteristics of preventable hospitalizations for ambulatory care-sensitive conditions (ACSCs) have been described, less is known about patterns of emergency and other acute care utilization for ACSCs among children who are not hospitalized. We sought to describe patterns of utilization for ACSCs according to the initial site of care and to determine characteristics associated with seeking initial care in an acute care setting rather than in an office. A better understanding of the sequence of health care utilization for ACSCs may inform efforts to shift care for these common conditions to the medical home. METHODS: We performed a retrospective analysis of pediatric encounters for ACSCs between 2017 and 2019 using data from the IBM Watson MarketScan Medicaid database. The database includes insurance claims for Medicaid-insured children in 10 anonymized states. We assessed the initial sites of care for ACSC encounters, which were defined as either acute care settings (emergency or urgent care) or office-based settings. We used generalized estimating equations clustered on patient to identify associations between encounter characteristics and the initial site of care. RESULTS: Among 7,128,515 encounters for ACSCs, acute care settings were the initial site of care in 27.9%. Diagnoses with the greatest proportion of episodes presenting to acute care settings were urinary tract infection (52.0% of episodes) and pneumonia (44.6%). Encounters on the weekend (adjusted odds ratio [aOR] 6.30, 95% confidence interval [CI] 6.27-6.34 compared with weekday) and among children with capitated insurance (aOR 1.55, 95% CI 1.54-1.56 compared with fee for service) were associated with increased odds of seeking care first in an acute care setting. CONCLUSIONS: Acute care settings are the initial sites of care for more than one in four encounters for ACSCs among publicly insured children. Expanded access to primary care on weekends may shift care for ACSCs to the medical home.

Comparison of Vital Sign Cutoffs to Identify Children With Major Trauma.

Importance: Vital signs are essential components in the triage of injured children. The Advanced Trauma Life Support (ATLS) and Pediatric Advanced Life Support (PALS) physiologic criteria are frequently used for trauma assessments. Objective: To evaluate the performance of ATLS and PALS criteria vs empirically derived criteria for identifying major trauma in children. Design, Setting, and Participants: This retrospective cohort study used 2021 American College of Surgeons Trauma Quality Improvement Program (TQIP) data contributed by US trauma centers. Included encounters involved pediatric patients (aged <18 years) with severe injury, excluding those who experienced out-of-hospital cardiac arrest, were receiving mechanical ventilation, or were transferred from another facility. Data were analyzed between April 9 and December 21, 2023. Exposure: Initial hospital vital signs, including heart rate, respiratory rate, and systolic blood pressure (SBP). Main Outcome and Measures: Major trauma, determined by the Standard Triage Assessment Tool, a composite measure of injury severity and interventions performed. Multivariable models developed from PALS and ATLS vital sign criteria were compared with models developed from the empirically derived criteria using the area under the receiver operating characteristic curve. Validation of the findings was performed using the 2019 TQIP dataset. Results: A total of 70 748 patients (median [IQR] age, 11 [5-15] years; 63.4% male) were included, of whom 3223 (4.6%) had major trauma. The PALS criteria classified 31.0% of heart rates, 25.7% of respiratory rates, and 57.4% of SBPs as abnormal. The ATLS criteria classified 25.3% of heart rates, 4.3% of respiratory rates, and 1.1% of SBPs as abnormal. Among children with all 3 vital signs documented (64 326 [90.9%]), PALS had a sensitivity of 88.4% (95% CI, 87.1%-89.3%) and specificity of 25.1% (95% CI, 24.7%-25.4%) for identifying major trauma, and ATLS had a sensitivity of 54.5% (95% CI, 52.7%-56.2%) and specificity of 72.9% (95% CI, 72.6%-73.3%). The empirically derived cutoff vital sign z scores had a sensitivity of 80.0% (95% CI, 78.5%-81.3%) and specificity of 48.7% (95% CI, 48.3%-49.1%) and area under the receiver operating characteristic curve of 70.9% (95% CI, 69.9%-71.8%), which was similar to PALS criteria (69.6%; 95% CI, 68.6%-70.6%) and greater than ATLS criteria (65.4%; 95% CI, 64.4%-66.3%). Validation using the 2019 TQIP database showed similar performance to the derivation sample. Conclusions and Relevance: These findings suggest that empirically derived vital sign criteria strike a balance between the sensitivity of PALS criteria and the specificity of ATLS criteria in identifying major trauma in children. These criteria may help to identify children at greatest risk of trauma-related morbidity and mortality.

Factors Associated with Pathway-Concordant Neuroimaging for Pediatric Ischemic Stroke.

OBJECTIVE: To determine factors associated with magnetic resonance imaging (MRI) and noninvasive diagnostic angiography among children presenting to the emergency department (ED) with acute ischemic stroke. STUDY DESIGN: We performed a cross-sectional study using data from >50 US children's hospitals. We included children 29 days through 17 years old hospitalized from the ED with an International Classification of Diseases, Tenth Revision, Clinical Modification, diagnosis code for acute ischemic stroke between October 1, 2015, and November 30, 2022. We excluded children with a principal diagnosis code of trauma/external injury, without neuroimaging on day of presentation, and into-ED transfers. Our outcomes were defined as acquisition of MRI (vs computed tomography only) and angiography (vs no angiography) on day of presentation. We performed generalized linear mixed modeling with hospital as a random effect to determine the association of demographics, known comorbidities, and treatment factors with each outcome. RESULTS: We included 1601 children. In multivariable analysis, younger age, mechanical ventilation, and Black race were associated with lower odds of MRI acquisition, whereas history of moyamoya disease and sickle cell disease were associated with greater odds. Younger age, mechanical ventilation, Hispanic ethnicity, Black race, other races, history of metabolic disease, and history of seizures were associated with lower odds of angiography. CONCLUSIONS: Younger and non-White children experienced lower odds of MRI and angiography, which may be driven by health system limitations or provider implicit biases or both. Our results expose risk factors for underdiagnosis of ischemic stroke and provide opportunities to tailor institutional pathways reflective of underlying pathophysiology.

External Validation of Empirically Derived Vital Signs in Children and Comparison to Other Vital Signs Classification Criteria.

OBJECTIVE: Various vital sign ranges for pediatric patients have differing utility in identifying children with serious illness or injury requiring immediate intervention. While commonly used ranges are derived from samples of healthy children, limited research has explored the utility of those derived from real-world encounters by emergency medical services (EMS). We first sought to externally validate pediatric vital sign ranges empirically derived from the prehospital setting. Second, we compared the proportion of children who received prehospital interventions using current common classification systems versus empirically derived vital sign ranges. METHODS: We retrospectively reviewed pediatric (<18 years) prehospital records from the 2021 ESO Collaborative dataset. We compared the proportions of encounters having vital signs (heart rate, respiratory rate, and systolic blood pressure) at the cutoffs of >99th, >95th, >90th, <10th, <5th and <1st centiles to previously reported centiles derived from EMS encounters in 2019-2020. We compared the deviation of mean Z-score by age between data sources. We identified the proportion of encounters with extreme (defined as <10th or >90th centile) vital signs who received prehospital interventions for the empirically derived criteria to six other classification criteria. RESULTS: 510,414 encounters were included, of which 66.9% were for medical indications and 70.7% resulted in hospital transport. The study sample had similar proportions of encounters identified at studied cutoffs compared to the previously published derivation sample, with all differences in proportions ≤1.1% between samples. All mean Z-scores were within 0.2 standard deviations of those from the derivation sample for each vital sign. Using empirically derived criteria, 34.2% had at least one extreme vital sign, compared to 69.1% with Pediatric Advanced Life Support criteria. Empirically derived extreme vital signs identified a higher proportion of children requiring most prehospital interventions compared to other vital signs criteria. CONCLUSION: Previously published empirically derived centiles for pediatric prehospital vital signs were replicated in this large multi-agency dataset. Compared to commonly used vital sign ranges, empirically derived criteria identified a higher proportion of children who received key prehospital interventions. Future steps include evaluating the role of these criteria in predictive models for in-hospital outcomes.

Completeness of Pediatric Versus Adult Patient Assessment Documentation in the National Emergency Medical Services Information System.

BACKGROUND: Pediatric prehospital encounters are proportionally low-frequency events. National pediatric readiness initiatives have targeted gaps in prehospital pediatric assessment and management. Regional studies suggest that pediatric vital signs are inconsistently obtained and documented. We aimed to assess national emergency medical services (EMS) data to evaluate completeness of assessment documentation for pediatric versus adult patients and to identify the documentation of condition-specific assessments. METHODS: We performed a retrospective cross-sectional analysis of EMS encounters from the National Emergency Medical Services Information System for 2019, including all 9-1-1 encounters resulting in transport. Our primary outcome was the proportion of encounters with complete vital signs (heart rate, respiratory rate, and systolic blood pressure) documented by pediatric age category relative to adult encounters. Pediatric patients were considered as those less than 18 years old. Our secondary outcome was condition-specific assessments for encounters with respiratory emergencies, cardiac complaints, and trauma. We performed multivariable logistic regression to calculate odds ratios (OR) and 95% confidence intervals (95% CI) for vital signs documentation by age after adjusting for sex, injury status, transport type (advanced vs basic life support), census region, urbanicity, organization nonprofit status, and organization type. RESULTS: Of 18,918,914 EMS encounters, 6.4% involved pediatric patients. Documentation of complete vital signs was lowest in those <1 month old (30.8%) and rose with increasing age (highest in adults; 91.8%). Relative to adults, the adjusted odds of documented complete vital signs in patients <1 month old was 0.03 (95% CI 0.03-0.03) and increased with age to 0.76 (95% CI 0.75-0.77) in those 12-17 years old. Among those patients with respiratory, cardiac, and traumatic complaints, children had lower proportions of documented pulse oximetry, monitor use, and pain scores, respectively, compared to adults. CONCLUSION: Documentation of complete vital signs and condition-specific assessments occurs less frequently in children, especially in younger age groups, as compared to adults, which is a finding that exists across urbanicity, region, and level of response. These findings provide a benchmark for clinical care, quality improvement, and research in the prehospital setting.

Characteristics of pediatric behavioral health emergencies in the prehospital setting.

OBJECTIVE: Approximately 10% of emergency medical services (EMS) encounters in the United States are behavioral health related, but pediatric behavioral health EMS encounters have not been well characterized. We sought to describe demographic, clinical, and EMS system characteristics of pediatric behavioral health EMS encounters across the United States and to evaluate factors associated with sedative medication administration and physical restraint use during these encounters. METHODS: We conducted a retrospective cross-sectional study of pediatric (<18 years old) behavioral health EMS encounters from 2019 to 2020 using the National Emergency Medical Services Information System. Behavioral health encounters were defined using primary or secondary impression codes. We used multivariable logistic regression to identify factors associated with sedative medication administration and physical restraint use. RESULTS: Of 2,740,271 pediatric EMS encounters, 309,442 (11.3%) were for behavioral health. Of pediatric behavioral health EMS encounters, 85.2% of patients were 12-17 years old, 57.3% of patients were female, and 86.6% of encounters occurred in urban areas. Sedative medications and physical restraints were used in 2.2% and 3.0% of pediatric behavioral health EMS encounters, respectively. Sedative medication use was associated with the presence of developmental, communication, or physical disabilities relative to their absence (adjusted odds ratio [aOR] 3.38, 95% confidence interval [CI] 2.93-3.91) and with encounters in the West relative to the South (aOR 1.23, 95% CI 1.16-1.32). Physical restraint use was associated with encounters by patients 6-11 years old relative to those 12-17 years old (aOR 1.35, 95% CI 1.27-1.44), the West relative to the South (aOR 3.49, 95% CI 3.27-3.72), and private nonhospital EMS systems relative to fire departments (aOR 3.39, 95% CI 3.18-3.61). CONCLUSIONS: Among pediatric prehospital behavioral health EMS encounters, the use of sedative medications and physical restraint varies by demographic, clinical, and EMS system characteristics. Regional variation suggests opportunities may be available to standardize documentation and care practices during pediatric behavioral health EMS encounters.

Injury patterns and mortality associated with near-hanging in children.

BACKGROUND: The pathophysiology of near-hanging in children is different from that of adults due to anatomic, physiologic, and injury-related mechanisms, with evidence suggesting that blunt cerebrovascular injuries (BCVI) and cervical spine injuries (CSI) are uncommon. We sought to estimate the incidence of secondary injuries and their association with mortality in pediatric near-hanging victims. METHODS: We performed a retrospective observational study of children (≤17 years) with a diagnosis code for hanging between October 1, 2015 and February 28, 2023 who presented to one of 47 geographically diverse US children's hospitals. We evaluated the incidence of the following secondary injuries: cerebral edema, pneumothorax, pulmonary edema, BCVI, and CSI. We performed Fisher's exact test with Bonferroni correction to identify associations between intentionality, sex, age, and secondary injuries with mortality. RESULTS: We included 1929 children, of whom 33.8% underwent neuroimaging, 45.9% underwent neck imaging, and 38.7% underwent neck angiography. The most common injury was cerebral edema (24.0%), followed by pulmonary edema (3.2%) and pneumothorax (2.8%). CSI (2.1%) and BCVI (0.9%) occurred infrequently. Cerebral edema, pneumothorax, pulmonary edema, and younger age (≤12 years) were associated with mortality. CONCLUSIONS: In this multi-center study of pediatric near-hanging victims, BCVI and CSI occurred rarely and were not associated with mortality. While children in our study underwent neck imaging more frequently than head imaging, cerebral edema occurred more often than other injury types and imparted the highest mortality risk. Given the rarity of BCVI and CSI, a selective approach to neck imaging may be warranted in pediatric near-hanging events.

Establishing outcome-driven vital signs ranges for children in the prehospital setting.

BACKGROUND: Vital signs are frequently used in pediatric prehospital assessments and guide protocol utilization. Common pediatric vital sign classification criteria identify >80% of children in the prehospital setting as having abnormal vital signs, though few receive lifesaving interventions (LSIs). We sought to identify data-driven thresholds for abnormal vital signs by evaluating their association with prehospital LSIs. METHODS: We evaluated prehospital care records for children (<18 years) transported to the hospital during 2022 from a large, national repository of emergency medical services (EMS) patient encounters. Predictors of interest were heart rate (HR), respiratory rate (RR), systolic blood pressure (SBP), and pulse oximetry. HR, RR, and SBP were converted to Z-scores using age-based distributional models. Our outcome was potential LSIs, defined as performance of selected respiratory procedures, resuscitative interventions, or medication administrations. Using cut point analysis, we identified higher specificity (maximal specificity with a minimum of 25% sensitivity) and higher sensitivity (maximal sensitivity with a minimum of 25% specificity) ranges for each vital sign and evaluated measures of diagnostic accuracy. RESULTS: We included 987,515 children (median age 10 years, IQR 2-15 years). An LSI occurred in 4.3% (2.1% with respiratory procedures, 1.2% with resuscitative interventions, and 2.0% with medication administration). HR, RR, and SBP demonstrated a U-shaped association with LSIs. Specificities ranged from 84.1% to 93.7% for higher specificity criteria, with RR demonstrating the best performance (sensitivity 84.6%, specificity 27.0%). Sensitivities ranged from 62.3% to 84.4% for higher sensitivity criteria. CONCLUSIONS: Cut points for pediatric vital signs were associated with LSIs. Specific age-adjusted ranges can identify children at higher and lower risk for receipt of LSI. These ranges may be combined with other objective measures to improve the assessment of children in the prehospital setting, assist in optimizing protocol utilization, improve transport decision making, and guide destination selection.

Clinician Management Practices for Infants With Hypothermia in the Emergency Department.

BACKGROUND: Young infants with serious bacterial infections (SBI) or herpes simplex virus (HSV) infections may present to the emergency department (ED) with hypothermia. We sought to evaluate clinician testing and treatment preferences for infants with hypothermia. METHODS: We developed, piloted, and distributed a survey of ED clinicians from 32 US pediatric hospitals between December 2022 to March 2023. Survey questions were related to the management of infants (≤60 days of age) with hypothermia in the ED. Questions pertaining to testing and treatment preferences were stratified by age. We characterized clinician comfort with the management of infants with hypothermia. RESULTS: Of 1935 surveys distributed, 1231 (63.6%) were completed. The most common definition of hypothermia was a temperature of ≤36.0°C. Most respondents (67.7%) could recall caring for at least 1 infant with hypothermia in the previous 6 months. Clinicians had lower confidence in caring for infants with hypothermia compared with infants with fever (P < .01). The proportion of clinicians who would obtain testing was high in infants 0 to 7 days of age (97.3% blood testing for SBI, 79.7% for any HSV testing), but declined for older infants (79.3% for blood testing for SBI and 9.5% for any HSV testing for infants 22-60 days old). A similar pattern was noted for respiratory viral testing, hospitalization, and antimicrobial administration. CONCLUSIONS: Testing and treatment preferences for infants with hypothermia varied by age and frequently reflected observed practices for febrile infants. We identified patterns in management that may benefit from greater research and implementation efforts.

Correlation of vital sign centiles with in-hospital outcomes among adults encountered by emergency medical services.

BACKGROUND: Vital signs are a critical component of the prehospital assessment. Prior work has suggested that vital signs may vary in their distribution by age. These differences in vital signs may have implications on in-hospital outcomes or be utilized within prediction models. We sought to (1) identify empirically derived (unadjusted) cut points for vital signs for adult patients encountered by emergency medical services (EMS), (2) evaluate differences in age-adjusted cutoffs for vital signs in this population, and (3) evaluate unadjusted and age-adjusted vital signs measures with in-hospital outcomes. METHODS: We used two multiagency EMS data sets to derive (National EMS Information System from 2018) and assess agreement (ESO, Inc., from 2019 to 2021) of vital signs cutoffs among adult EMS encounters. We compared unadjusted to age-adjusted cutoffs. For encounters within the ESO sample that had in-hospital data, we compared the association of unadjusted cutoffs and age-adjusted cutoffs with hospitalization and in-hospital mortality. RESULTS: We included 13,405,858 and 18,682,684 encounters in the derivation and validation samples, respectively. Both extremely high and extremely low vital signs demonstrated stepwise increases in admission and in-hospital mortality. When evaluating age-based centiles with vital signs, a gradual decline was noted at all extremes of heart rate (HR) with increasing age. Extremes of systolic blood pressure at upper and lower margins were greater in older age groups relative to younger age groups. Respiratory rate (RR) cut points were similar for all adult age groups. Compared to unadjusted vital signs, age-adjusted vital signs had slightly increased accuracy for HR and RR but lower accuracy for SBP for outcomes of mortality and hospitalization. CONCLUSIONS: We describe cut points for vital signs for adults in the out-of-hospital setting that are associated with both mortality and hospitalization. While we found age-based differences in vital signs cutoffs, this adjustment only slightly improved model performance for in-hospital outcomes.

Hospitalization and evaluation of brief resolved unexplained events (BRUEs) from a statewide sample.

OBJECTIVE: The 2016 clinical practice guideline (CPG) replacing apparent life-threatening event (ALTE) with brief resolved unexplained event (BRUE) was associated with a reduction in hospitalizations and clinical testing among children with this condition in pediatric hospitals. However, as only a minority of acute-care encounters occur in dedicated pediatric centers, the overall effect of this CPG on children with ALTE/BRUE remains unknown. The purpose of this study is to examine changes in the diagnosis and management of BRUE in a statewide sample of non-pediatric hospitals following publication of the CPG. METHODS: This is a retrospective study of encounters of infants (<1 year) presenting to 178 non-pediatric Illinois Emergency Departments (EDs) between 2013 and 2019 with an International Classification of Disease (ICD) 9th and 10th revision billing code of ALTE or BRUE (799.82, ICD-9; R68.13, ICD-10). Our primary outcomes were counts of ALTE/BRUE and the percent of patients with ALTE/BRUE admitted and/or transferred to another facility. Our secondary outcome was clinical testing. We used interrupted time-series analysis for our primary outcome and chi-square testing for secondary outcomes. Results were stratified into academic and community EDs. RESULTS: This study included 4639 ED encounters for infants with BRUE that presented to academic EDs (2229; 48.0%) or community EDs (2410; 52.0%). At academic EDs, ALTE/BRUE diagnoses were increasing by 2.3 per quarter prior to the CPG publication and decreased by 0.5 per quarter after the CPG publication, representing a change in slope of -2.8 per quarter (p < 0.01). The percent of ALTE/BRUE patients admitted/transferred was decreasing by 0.1% per quarter in the pre-intervention period and decreased by 0.3% per quarter in the post-intervention period, representing a change in slope of 0.7% (p = 0.03). At community EDs, ALTE/BRUE diagnoses were increasing by 2.9 per quarter prior to the CPG publication and increased by 1.4 per quarter after the CPG publication, a non-significant change in slope. The percent of ALTE/BRUE patients admitted/transferred was decreasing by 1.6% in the pre-intervention period and decreased by 0.9% in the post-intervention period, a non-significant change in slope. At academic EDs, there was no significant change in clinical testing. At community EDs, a lower proportion of patients in the post-intervention period had chest radiographs, blood cultures, metabolic panels, blood counts, and urine testing, while a higher proportion had pertussis testing and respiratory pathogen testing. CONCLUSIONS: Counts of BRUE diagnoses and the overall proportion of children admitted or transferred showed a consistent decrease at academic EDs but had a nonsignificant change in trend at community EDs following the CPG publication in 2016. There was no significant change in clinical testing at academic EDs while community EDs had a significant decrease in some testing and an increase in other types of testing. Our findings suggest the need for greater implementation efforts in non-pediatric settings, specifically community EDs, where pediatric patients with BRUE present infrequently in order to optimize care for these children.