UMEM Educational Pearls - By Jenny Guyther

Children account for up to 20% of emergency department visits.  In the US, up to 90% of children’s visits to emergency departments are to general EDs.  The weighted pediatric readiness score (WPRS) was developed to assess the level of readiness of emergency departments to care for pediatric patients. The last assessment was in 2013 showed a mean score of 68.9.  High readiness scores have been associated with decreased mortality.  The same holds true for children with injuries presenting to trauma centers.  The higher the WPRS score, the lower the risk of in hospital death.  There was no difference if the patient presented in cardiac arrest.  A 10 point increase in WPRS is associated with a lower odds of potentially avoidable transfers in both trauma and medical patients.  More recent data has been collected, but has not yet been published.  More information on pediatric readiness (for hospitals and EMS) can be found at: https://emscimprovement.center/domains/pediatric-readiness/. 

Bottom line: Being Pediatric Ready improves the care of children.

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Early defibrillation is a key step in the cardiac arrest chain of survival.  Public Access AEDs may be available more readily than waiting for first responders.  Outside of simple awareness of where AEDs are located, there are newer ways to become aware of public AEDs near a cardiac arrest including cell phone apps or information given by 911.  A British study showed that only 5.9% of AEDs were within 100 meters of the patient and 35% were within 500 meters.  The distance between the AED and arrest may be a barrier for bystander AED use.  This study looked to determine the time required to retrieve an AED and they hypothesized that a distance > 400 meters would be longer than the EMS response times. 

This study used 15 women and 15 men to perform different runs in various environments in different seasons, retrieving AEDs at 200m through 600m and bringing it back to the patient.  In these scenarios, only the 200m distance (400 m round trip) times were deemed to allow enough time to apply and use the AED prior to EMS arrival.  Barriers to AED retrieval included traffic lights, cars, weather and pedestrians.

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Premature infants in the NICU are often given caffeine to help to prevent apneic episodes and this has been proven safe.  This study aims to determine if caffeine will help infants < 8 weeks with bronchiolitis, even if there is no concern for apnea. The current recommended treatment for bronchiolitis is supportive care.

2 French Hospitals with the same protocols and resources for bronchiolitis participated.  All infants admitted to each hospital with a diagnosis of bronchiolitis were included.  Infants who presented to Hospital A received caffeine and infants who presented to hospital B did not.  The remainder of their care was similar.  The caffeine was given as a bolus dose followed by a daily maintenance dose until there was clinical improvement.  The dose was the standard dose used in premature infants with apnea as recommended by the French National Authority for Health.  There were 26 patients at the study hospital that did not receive caffeine for an unknown reason.  65 patients received caffeine.

The study had several areas showing statistical significance:

In the subgroup of RSV + patients, those who did NOT receive caffeine had a higher incidence of requiring ventilatory support.  

The use of high flow nasal cannula was HIGHER in the group with NO caffeine.

The use of CPAP was HIGHER in the caffeine group BUT the duration of CPAP use was shorter compared to the NO caffeine group.

The need for nutritional support was higher in the NO caffeine group.

There were a few cases of temporary tachycardia and irritability in the caffeine group which resolved several hours after the medication was given.

A larger study is needed, but in this small group, there may be an indication for caffeine outside of the NICU for infants < 8 weeks.

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This was a European study examining a screening tool to be used in the ED to indicate the need for further investigation into the concern for possible abuse.  Four questions were taken from other commonly used abuse screening tools that were used outside of the ED.  SCAN questions are as follows:

1. Is the injury compatible with the history, and does it correspond to the child's developmental level?

2. Was there an unnecessary delay in seeking medical help?

3. Is the behavior/interaction of the child and caregivers appropriate?

4. Are there other signals that make you doubt the safety of the child or family?

Any positive answer triggered further evaluation, starting with a complete head to toe assessment and complete history with additional tests added as warranted.  This is only a screening tool and positive answers do NOT mean that abuse has occurred, but should cause you to pause and think further.

These questions showed a "moderate" performance among close to 25000 patients and the questions were comparable in children < 5 years to other/longer screening tools used in Europe.

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There is no standardized prehospital neonatal resuscitation curriculum for EMS.  The Neonatal Resuscitation Program (NRP) guidelines focus on hospital based births which may not translate to the prehospital environment.

This study was prospective and observational that used a virtual, EMS tailored newborn resuscitation curriculum.  Initially, 350 EMS clinicians watched a 90 min video.  This was then modified based on their feedback to a 60 minute interactive curriculum specifically designed for EMS that emphasized NRP concepts and reinforced how NRP was different from pediatric resuscitation.  17 EMS jurisdictions viewed the program and were then given a brief NRP based quiz before, after and 3 months following the training.  

Feedback was overall positive and post test and 3 month follow up test scores showed improvement from the pre test scores.

Standardized neonatal resuscitation education represents an area where improvements can be made in prehospital education.  This particular curriculum was well received and improved EMS clinicians knowledge based.  Jurisdictional medical directors should work with their department on standardized education for the neonatal population.

Also, stay tuned for updated NRP guidelines which are due to come out this fall.

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Unplanned extubation (UE) occurs in 0-25 % of patients intubated in the prehospital setting and transfer of patient care is one time where UE can occur.  This EMS jurisdiction wanted to improve the rate of communication and confirmation of tube placement at the time of patient transfer.  Over 5 months, the jurisdiction introduced 1) memorandums to paramedics, ED chiefs and respiratory therapist leads, 2) individualized paramedic feedback emails and 3) PCR changes that resulted in documentation of tube placement at transfer of care being a mandatory field. 

Initially the rate of verbal ETT position at transfer of care was 74%.  This increased to > 90% after 8 weeks.  The rate of UE was 2/340 patients.  The implementation of this project showed improvements in perceived accountability, interprofessional relationships and satisfaction with interventions that were noted in the post project focus group.

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The first attempt success rates for neonatal intubation is less than 50%.  Video laryngoscopy (VL) has been shown to improve state first pass success compared to direct laryngoscopy (DL) in both children and adults, but few studies have looked at the neonatal population.

This study was a randomized control trial.  There was a 74% first pass success rate for VL compared to a 45% first pass success rate for DL.  There were no differences in secondary outcomes which include hypoxia, bradycardia, epinephrine administration, oral trauma and correct positioning.

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Trauma is a leading cause of death in pediatric patients.  The  Pediatric Traumatic Hemorrhagic Shock Consensus Conference Recommendations have stated that blood products are better than crystalloid and recommend the use of low titer type O whole blood (LTOWB) over individual components for pediatric traumatic resuscitation.

This study used the Trauma Quality Improvement Program Database to look at 1122 pediatric patients (< 18 years) over a 3 year period to retrospectively examine the impact of the ratio of whole blood and blood products given during the resuscitation of these patients. When at least 30% of the blood products delivered within the first 4 hours of resuscitation were low titer O whole blood, survival improved at the 6, 12 and 24 hour time mark.
 

The authors concluded that the observed survival benefit supports the greater availability and use of LTOWB during pediatric trauma resuscitation.

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This was a multicenter retrospective cohort study over 6 years at 7 level one and two trauma centers.

1631 patients who had out of hospital traumatic cardiac arrest were included. The majority of the patients were adults, female, suffered penetrating trauma (64%) and were in a non-shockable rhythm.  Prehospital epinephrine was given to 54% of patients.

Overall, survival to hospital discharge was lower in the epinephrine group (5% vs 16%).  In the penetrating trauma subgroup, there was no statistically significant survival difference in patients who received epinephrine and those who did not. 

EMS jurisdictions should examine their trauma arrest protocols and consider excluding the use of epinephrine.  Several states, such as Maryland, have already removed epinephrine from the trauma arrest protocol.

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Intranasal (IN) midazolam is often used for anxiolysis in pediatrics prior to procedures.  In this study, 0.2 mg/kg of IN midazolam (up to 6 mg total dose) was given prior to laceration repair in children 2-10 years.

90% of children were at least minimally sedated at the start of the procedure and these children also displayed less anxiety when measured on a standardized anxiety scale.  

Children's whose procedure started 10-20 minutes after IN medication compared to 25-35 minutes had significantly lower anxiety.

IN midazolam can be successful as an anxiolytic, but careful attention should be directed at the timing of the procedure.

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GCS was first introduced in 1974 and now includes a preverbal version for patients < 2 years.

This study looked for non inferiority between motor Glascow Coma Scale (mGCS) and the total GCS in pediatric patients.  The study also examined if a mGCS<6 was non inferior to a GCS < 14 in children.  582 patients < 18 years were reviewed in this retrospective review.

The mGCS  was noninferior to total GCS as a triage tool in pediatric trauma. It also validated the use of mGCS <6 in place of GCS <14 in the field with identification of children at risk of death or requiring ICU care.

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33 paramedics had a short course in thoracic point of care ultrasound.  There was a pre and post test that included the history and physical exam for patient scenarios with COPD and CHF exacerbations.  Paramedics were asked to select the appropriate treatments.  The post test included ultrasound images.  Diagnostic accuracy in the post test improved by 17% and appropriate treatment selection improved by 23%.  Paramedics were also able to correctly identify ultrasound images 90% of the time.

Bottom line: Introducing thoracic ultrasound to paramedics can improve patient care.

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While there are numerous evidence-based recommendations for the management of febrile infants, there are not clear guidelines for the management of hypothermic infants (0-90 days).

A recent review article offered the following summary points from the literature:

The World Health Organization defines hypothermia as a temperature < 36.4 degrees Celsius while the International Pediatric Sepsis Consensus Conference uses < 36.0 degrees Celsius.  A multicenter study attempted to empirically derive a threshold for hypothermia but was not successful.

One study looking at the age of presentation of hypothermic patients showed that > 50% of the infants that presented were < 7 days old.

There are numerous reasons that an infant can be hypothermic, including bacterial infections such as urinary tract infections, bacteremia or meningitis, viral infections (herpes simplex virus) or environmental factors.  Premature infants can also have temperature instability as can those with insufficient caloric intake.

Serious bacterial infection (defined as urinary tract infections, bacteremia or meningitis ) occurred less frequently in hypothermic infants compared to febrile infants, but the rates of invasive bacterial infections (defined as bacteremia and meningitis) were the same between the two groups.

In 112 patients with neonatal HSV, 5.2% of the cases were hypothermic, 30.9% had fever and 63.9% had no change in temperature.

Important questions/exam findings to raise suspicion for a pathological cause of hypothermia:

Perinatal history: Gestational age, GBS and HSV status of mom, perinatal antibiotics, and potential exposures to HSV.

Weight change, activity change, interest in feeding, abnormal movements, changes in breathing pattern, ill appearance

Some institutions will group the evaluation of hypothermic infants into the febrile infant guidelines, but there are currently no evidence-based pathway's.  Striking a balance between over testing and not missing a serious bacterial infection is difficult and an area that requires additional research.

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Have you been wondering what the latest pediatric emergency medicine lecture says?

See the attached table from this review which highlights the 10 top articles from 2024 with their key findings!

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Attachments

• Top 10 PEM articles 2024-67ebfc5c9db41.pptx (238 Kb)

Pulseless electrical activity (PEA) is the initial rhythm in up to 25% of out of hospital cardiac arrests.  

This paper is a systemic review and analysis examining if the rate or width of the initial PEA qrs complex was associated with survival.  The qrs complex was either wide (>= 120 ms) or narrow (<120ms) and a frequency of fast (>= 60/s) or slow (<60/s).  7 studies including 9727 patients were included.  Analysis showed:

- mortality was higher in the wide qrs group compared to narrow

- mortality was higher in the slow PEA rate compared to fast

- neurological outcome was better in patients with a fast PEA rate compared to slow.

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This was a retrospective analysis of pediatric cardiac arrests that occurred out of hospital in Japan, where no pediatric termination of resuscitation is allowed.  1007 arrests were included.  Patients that were placed on ECMO were excluded.  This study included both medical and traumatic arrests looking at a primary outcome of 1 month moderate or better neurological disability.  CPR time for both EMS and the hospital prior to ROSC were included.  Bystander CPR was not included in these calculations.  Possible downtime prior to CPR was not taken into consideration.

Overall, less than 1% of pediatric patients exhibited one-month moderate disability or better neurological outcome when total CPR duration is more than 64 minutes.

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A few states have pediatric out of hospital termination of resuscitation protocols.  This study used CARES data to create a termination protocol that was not only linked to ROSC, but also to neurological outcomes.  This study only included medical arrests.
 

21240 children were included in the study where 2326 patients survived to hospital discharge.  A total of 1894 survived with a favorable neurological outcome.  The criteria developed for pediatric TOR in this study had a specificity of 99.1% and a PPV of 99.8% for patient death.  Another set of criteria had a 99.7% specificity and PPV of 99.9% for predicting death or survival with poor neurological outcome.

TOR criteria of death consisted of:

1. unwitnessed arrest

2. asystole

3. arrest not due to drowning or electrocution

4. no sustained ROSC

TOR criteria of death or survival with poor neurological outcome:

1. unwitnessed arrest

2. asystole

3. arrest not due to drowning or electrocution

4. no sustained ROSC

5. no bystander CPR

Bottom line: Pediatric termination of resuscitation in the out of hospital setting can be appropriate under the right set of conditions.

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This was a retrospective cohort study of the national trauma data bank that included about 64000 pediatric trauma patients in the derivation group and the same amount in the validation group.  The authors empirically created upper and lower cut off values for the shock index based on age.  They compared the shock index based on age cut offs with major trauma as defined by the standardized triage assessment tool criteria.  

The empirically derived age adjusted values had a sensitivity of 43.2% and a specificity of 79.4% for major trauma.  The sensitivity of the pediatric shock index (PSI) in that same group was 33.9% with a specificity of 90.7%. The pediatric-adjusted shock index (SIPA) had a 37.4% sensitivity and 87.8% sensitivity for 4-16 year olds.

Shock index = (Heart Rate / Systolic BP)  

• Shock Index, Pediatric Adjusted (SIPA)
  • 4-6 years = 1.2
  • 6-12 years = 1
  • > 12 years = 0.9
  • Patients with an elevated SIPA had a 3.82 odds of major trauma compared to those with a normal SIPA.

Pediatric Shock Index (PSI)

For children age 1-12 years

SI > 1.55 - (0.5) x (age in years)

Patients with an elevated shock index had a 5.02 greater odds of major trauma in this study.  

This study used age specific cut offs such as:

1 yr to < 3 years = lower limit of 0.73 and an upper limit of 1.40

(see article for a full table).

Patients with a shock index below the lower limit had a 1.55 greater offs of major trauma and patients with a shock index above the upper limit had a 3.97 greater risk of major trauma.  

Bottom line: Shock index alone has a limited role in the identification of major trauma in children.  Of these three methods for calculating/interpreting shock index, PSI seemed to do better.

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Previous studies have suggested that a single dose of epinephrine in out of hospital cardiac arrests compared to multiple dose protocols result in a similar survival to hospital discharge rate.  This study aimed to see if single dose epinephrine compared to multiple doses improved survival in the subset of patients that were 1) in a shockable rhythm or 2) received bystander CPR.

This study looked at patients from 5 EMS systems in North Carolina before and after a protocol change from multiple dose epinephrine to single dose epinephrine in cardiac arrest.  1690 patients were included, 19.2% with a shockable rhythm and 38.9% who received bystander CPR.

The study found:

- Survival to hospital discharge was higher in the single dose epinephrine group who received bystander CPR

- Survival rates were similar in the single and multiple dose epinephrine groups for patients who were initially in shockable rhythms, in asystole/PEA and who did NOT receive bystander CPR.

Bottom Line: More studies are needed to support prehospital protocol changes.

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This was a retrospective, multicenter cross-sectional study of pediatric sedations over 3 years using the Pediatric Sedation Research Consortium database.

85,599 pediatric sedations were included.  These sedations did include the operating rooms.  

8.7% of sedations required an intervention for airway/breathing/circulation in patients who did NOT have procedural oxygenation while 10.1% of patients in the group that did have procedural oxygenation required an intervention.  The majority of these interventions were minor, ie airway repositioning.  The group that did have procedural oxygenation did have a lower rate of hypoxia compared to the group without procedural oxygenation (2.5% vs 4.5%).

The authors concluded that preemptive procedural oxygenation did NOT decrease the overall need for interventions in the ABCs compared to no procedural oxygenation.

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