UMEM Educational Pearls - By Jenny Guyther

This article was a review of randomized control trials using intranasal (IN) fentanyl.  There were 8 studies included that showed IN fentanyl was superior to controlling pain compared to other pain medications at the 15-20 minute mark, but not at the 30 and 60 minute marks.  There were less reports of nausea and vomiting with IN fentanyl, but no difference in dizziness or hallucinations compared to the other medications included in the various trials (ie morphine, ketamine, po narcotics, ect)

The bioavailability of IN fentanyl ranges from 71-89% with effects noted in 2 minutes with maximal concentrations noted at 7 minutes.  The half life is approximately 60 minutes.

Bottom line: Consider IN fentanyl for quick acute pain management in the pediatric patient.

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CHECK-CALL-COMPRESS  is the recommended algorithm by the International Liaison Committee on Resuscitation to teach school age children.  Several studies show that school aged children are highly motivated to learn and perform CPR.  They also serve as CPR multipliers meaning they go home, talk about what they have learned and inspire others to learn.

By age 4, children are able to assess the first step in the chain of survival - CHECK - assessing for responsiveness and breathing.  By age 6, children can dial the emergency number and give the correct information for the location of the call.  By age 10-12 children are able to get correct chest compression depths and ventilation volumes in CPR manikins.  Hands-on training is more beneficial compared to verbal only instruction.

Areas where CPR is taught to school age children as a part of the school curriculum have higher rates of bystander CPR.

Bottom line: CPR should be introduced to elementary school children.

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Question

EMS may call the hospital to obtain online medical direction when a patient does not wish to come to the hospital.  One difficult task faced by the physician at the hospital is determining the decision making capacity of the patient.  There is currently no nationally recognized standard protocol for physicians providing EMS oversight in this situation.  

The four components involved in the determination of capacity are: understanding, appreciation, reasoning and expression of choice.  This study used a modified Delphi approach with 19 physician experts to develop standardized steps to guide best practices for physicians who are called in real time about a patient refusing EMS transport.  Consensus was defined as 80% agreement.  

The example worksheet with the compilation of recommendations is attached.

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Attachments

• Refusal checklist table-670fb6a9192a8.docx (105 Kb)

This study looked at the success rates of femoral vs proximal tibial IOs in the prehospital setting.  Over a 9 year period, there were 163 pediatric patients who received either a tibial or femoral IO.  Femoral IOs were introduced into the EMS protocol in this study area in 2015 as a location option and were the recommended site starting in 2019.  The success rate of femoral IO placement was 89% and for proximal tibial sites was 84.7%.  After further data analysis the study found an adjusted odds ratio of 2 for successful IO placement in the distal femur compared to the proximal tibia.  The complication rates for both sites were similar.  

Bottom line: This study suggests that the distal femur is a reasonable site for IO access in the pediatric population.

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This study looks at the efficacy of ketamine vs. midazolam for the prehospital sedation of acutely agitated patients, examining the need for repeat sedation (by EMS or in the ED), adverse events and length of stay.

A greater number of patients required repeat sedation within 90 minutes with initial ketamine dosing compared to midazolam. There was no difference in patients receiving repeat sedation within 20 minutes between the two groups.

There were no significant differences in time to repeat sedation, total sedation doses (by EMS or in the ED), use of bag valve mask ventilation or intubation, use of physical restraints, admission location/level of care, or length of stay in the Emergency Department (ED), hospital, or Intensive Care Unit.

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Previous literature has shown that there is a survival difference between White and Black palpitations with regards to out of hospital cardiac arrest (OHCA) in the US.

This study looked at OHCA variables and outcomes among 5 racial/ethnic groups (White, Black, Asian, Hispanic, and Pacific Islander).  Data was collected from the CARES registry from 3 racially diverse counties.  The adjusted risk ratio for survival to hospital discharge was lower in all 4 other groups compared to patients where data entry identified the patient as White.  The risk difference for positive neurologic outcomes was also lower among Black, Asian, Hispanic, and Pacific Islander patients.

When looking at variables associated with the cardiac arrests, there were differences between the groups with regards to response location and bystander CPR.

Bottom line: Cardiac arrest recognition and CPR education needs to be inclusive of all racial/ethnic groups and focus on areas where disparities exist.

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This was an observational study where ultrasound was used to evaluate if the diaphragm came into view at the 5th intercoastal space (ICS) at the midaxillary line in pediatric patients during maximal respiration. A convenience sample of pediatric patients who presented to the an academic pediatric emergency department was used.

In 10.3% of patients, the diaphragm crossed the 5th ICS during normal respirations and 27.2% crossed during maximal respirations.  This was a more common occurrence on the right compared to the left.  An increase in body mass index was also associated with an increased risk of the diaphragm crossing the during both tidal respiration and maximal respirations.

Bottom line: Using a blind insertion of a chest tube at the 5th ICS, midaxillary line in the pediatric patient poses a not insignificant risk of piercing the diaphragm.  this study recommends using ultrasound prior to chest tube placement.

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Emergency department visits for pediatric mental health and behavioural concerns have been increasing.  This study attempted to further characterize medications, both home and for sedation, that were given to these patients.  

This study included 670,911 youth with a mental or behavioral health diagnosis over a 9 year inclusion period.  The most common diagnses were depressive disorder, suicide or self injury and disruptive, impulse control and conduct disorder.  During this time, a total of 12.3% of patients had a psychotropic medication given while in the ED.  The percentage and odds of administering these medications increased from 7.9% in 2013 to 16.3% in 2022.  Those with intellectual disability and autism spectrum disorder had the highest frequency of medication administration.  

Bottom line: As mental health visits in pediatrics continue to increase along with boarding times, clinicians should become more familiar with psychotropic medications used in this population and become comfortable in making sure that these patients have their home medications and have a plan for chemical sedation if other areas of de escalation fail.

Early administration of antibiotics for open fractures can reduce serious bone and soft tissue infections, with a common goal being antibiotic administration within one hour of injury.

In this study, there were 523 patients treated by EMS who had an open extremity fracture.

The median time from EMS dispatch until antibiotic administration was 31 minutes.  99% of the patients who received antibiotics received them within one hour of EMS dispatch.  Prehospital times were on average 10 minutes longer for those patients who received antibiotics.  The majority of these patients received cefazolin, followed by ceftriaxone, ampicillin, gentamicin and piperacillin/tazobactam.  None of these patients required management for an allergic reaction or anaphylaxis.  Five patients (1%) who received prehospital antibiotics and 159 patients who did not (1.4%) had a subsequent infection based on ICD codes.

Bottom line: In this small group, it was safe to administer antibiotics to a patient with an isolated open extremity fracture and the medication was able to be delivered earlier.  Larger studies will be needed to see the impact of this practice on the development of osteomyelitis or soft tissue infections.

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Teaching has circulated that a temperature of 40 degrees Celsius or above (hyperpyrexia), was associated with a greater incidence of serious bacterial infection.  However, this teaching originated in a time prior to the availability of childhood vaccinations. In fact, the largest retrospective study to support this used data from 1966-1974.  

2565 WELL APPEARING patients between the ages of 61 days and their 18th birthday who presented to a single tertiary care pediatric emergency department with the chief complaint of fever were included.  The prevalence of serious bacterial infection was compared to the presence of hyperpyrexia, age, chronic conditions, gender and vaccination status.

Serious bacterial infections (SBIs) included: deep space infections, appendicitis, pneumonia, mastoiditis, lymphadenitis, acute bacterial rhinosinusitis, urinary tract infection, pyelonephritis, cholecystitis, tubo-ovarian abscess, septic arthritis, osteomyelitis, bacteremia or bacterial meningitis.

There was NO statistically significant association between hyperpyrexia and SBIs. Older age and make sex were associated with a higher risk of SBIs.

Bottom line: In well appearing children 61 days and older, having a temperature >/= to 40 degrees was not associated with serious bacterial infections.

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Several studies have shown that patients who require a resuscitative thoracotomy (RT)  have a higher odds of survival if they are transported by police or in private vehicles.  This study examined 195 patients who required RT to see if prehospital intubation and out of hospital time (OOHT) affected ROSC rates.

There was no association between OOHT and ROSC and no association of OOHT and survival.  The mean OOHT for this study was only 25 minutes which is faster than other studies.  

The odds of ROSC were lower in patients who had ANY intubation attempts prior to arrival.

Bottom line: BLS airway management (or supraglottic placement) may be more beneficial for the trauma arrest patient in the prehospital setting.

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This was a cross sectional study examining insurance data to determine if there is seasonality related to ED visits and psychiatric hospitalizations related to suicidality.

Suicidality includes both suicidal ideation and suicide attempts (but not suicide).  One survey showed that up to 12% of US adolescents reported serious thoughts of suicide.  This study included 73,123 patients where 19.4% were direct inpatient admissions and 80.6% were ED visits, 44% of whom were subsequently admitted.

Metrics for suicidality in 10-18 year olds peaked in April and October with a nadir in June.  Incidentally, in the Spring of 2020 when US schools closed due to COVID, there was a decrease in both ED visits and hospitalizations with April and May having the lowest rates across the study period.

School is believed to increase stress with risk factors such as bullying and peer pressure, academic and extracurricular stressors and poor sleep hygiene.

Bottom line: There has been an increase in adolescent suicidality over the recent years, many of whom present to the ED for evaluation.  More mental health resources are needed, especially during the school year.

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Maternal morbidity continues to increase in the US with a mortality rate in 2021 of 39.2 deaths/100,000 live births.  There has been an intense focus on training and quality improvement within hospitals, but not much has changed in the prehospital education arena.  This study aimed to quantify the complications encountered by EMS clinicians.  

In the 2018-2019 EMS dataset used, there were a total of 56,735,977 EMS activations which included 8641 out of hospital deliveries, 1712 documented delivery complications and 5749 records of newborns.

1% of the out of hospital deliveries had a documented complication for the mother.  Of these complications, 94% were for hemorrhage, 6% for abnormal presentation, 0.2% for shoulder dystocia, and 0.4% for nuchal cord.  

Few patients had medications given, including 0.4% receiving oxytocin.  no patients received prehospital blood transfusion or TXA.  Of note, in the years since this data was obtained, TXA and whole blood have started to appear on more medic units, but it is still not necessarily commonplace.

Bottom line: While still rare, prehospital delivery does occur and EMS should be prepared for any possible complications.  Medical directors should look at their jurisdictional/state protocols to see if oxytocin/TXA or whole blood should be included (if not already available).  EMS clinicians should be educated on up to date management of OB emergencies.

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This was a multicenter, randomized double blind, placebo controlled, non inferiority trial looking at children aged 2 months to 10 years with a diagnosis of urinary tract infection to see if the antibiotic course could be shortened from 10 days to 5 days in those patients who have clinically improved by day 5.

Children were prescribed amoxicillin/clavulanic acid, cefixime, cefdinir, cephalexin or trimethoprim-sulfamethoxazole and on day 6, after an in person visit were switched to placebo or continued the same antibiotic course.

A urine sample was collected on days 11-14 and treatment failure was defined as symptomatic urinary tract infection at or before this visit, asymptomatic bacteriuria, positive urine culture or gastrointestinal colonization with resistant organisms.

693 children were randomized in this trial.  Children who received 5 days of antibiotics were more likely to have asymptomatic bacteriuria or a positive urine culture on days 11-14 (0.6 vs 4.2%).  28 children would need to be treated with a 10 day course to prevent one treatment failure with the 5 day course.

Bottom line: 10 days is still the ideal duration of treatment for a urinary tract infection, but the rate of failure of a 5 day course was low and the clinical significance of asymptomatic bacteriuria or a positive urine culture in an otherwise asymptomatic child is unknown.

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The short answer is yes, pediatric trauma patients without blood pressures recorded from EMS had a higher mortality (4.3%) compared to pediatric patients that did have a recorded blood pressure (1.1%). This is based off of a prehospital study conducted in Japan.

Prehospital vital signs are left out more often in pediatric patients compared to adults. Of those vital signs that are recorded, blood pressure is the most common one left off.

There can be several barriers to obtaining a blood pressure on the pediatric patient in the prehospital setting: lack of properly sized equipment, an uncooperative child, and lack of education. However, the inability to obtain a blood pressure can also be due to the patient being more severely injured and having other skills performed or was unable to be obtained due to poor perfusion. In this study, those who did not have a recorded blood pressure also had a lower GCS score and a higher injury severity score.

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7,365 suicide related cardiac arrests were included in this study that included a several year study period in Queensland Australia.  Cardiac arrests where resuscitation was attempted by EMS and where circumstances were concerning for suicide were included.  ROSC rates were 28.6% with survival at 30 days being only 8%.  30-day survival for medical cardiac arrests in this jurisdiction was 16.4%.  Overdose and poisoning had the best survival rate (19.9%), while hanging and chemical asphyxia were the worst (7.3 and 1.1% respectively).

Bottom line: Survival rates for suicide related out of hospital cardiac arrest were worse compared to other causes of medical arrest.  Suicide prevention should become a focus with emphasis on early identification and treatment of people at high risk of suicide.  While EMS is well trained on the management of cardiac arrest, training should also emphasize suicide risk assessment and identification.

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The gold standard for confirming ETT position is a chest xray, but this can often be delayed while the patient is stabilized. Many physicians will estimate ETT insertion depth to be 3x the ETT size, but this is based on selection of the correct tube.  There are several other published formulas, including the PALS guidelines [age in years/2 + 12] which applies to children older than one year.  In 1982, there was an article published that cited the formulas of [Height (cm) x 0.1 +5] or [Weight(kg)/5 + 12].

This was a retrospective study where the ideal position of cuffed ETT (from the front teeth) was determined by looking at post intubation xrays of 167 patients between 28 days and 18 years.  The individual optimal ETT insertion depth was plotted against age, weight and height for all children.  This study showed that there is not a fully linear relationship between age, height or weight which is a flaw of all of these formulas.  Calculations using the patients’ weight performed the worst.  Age based and height formulas performed the best.

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Vital signs in children can be difficult to remember since they vary with age.  Using a standardized card or app (such as PALS) can help EMS clinicians remember the values.  Most pediatric vital sign reference ranges were derived from samples of healthy children in the outpatient setting (ie PALS).  This study attempted to validate a range of pediatric vital signs that were more accurate in predicting the need for prehospital interventions compared to the standard PALS vital sign ranges. The thought was that by using EMS data, these vital sign ranges could better alert EMS to patients in need of acute intervention.

The authors used a large EMS database to determine the vital signs for the patients age and correlated that to prehospital interventions (including IV, medication, EKG, advanced airway management, ect).  They used the <10% and >90% for the age values (termed "extreme" vitals signs) as a cut off to be considered abnormal.  Using the EMS derived values, 17.8% of the encounters with an extreme vital sign received medication.  If the PALS abnormal vital sign range was used, only 15.2% of those patients were given medications.  Overall, encounters with an extreme vital sign had a higher proportion of any intervention being performed compared to other vital sign criteria (i.e. only 33.7% with PALS).

These extreme vital signs also had a greater accuracy in predicting mortality.

Bottom line: While vital signs are based on physiology that does not change based on location, using a seperate criteria for the EMS population, can improve discrimination between sick and sicker patients and hopefully allow EMS to recognize and intervene on sicker patients sooner.

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BACM stands for benign acute childhood myositis which is typically a benign, viral induced self limiting illness.  This was a retrospective study looking at 65 patients in Italy to further characterize the characteristics of the disease.

In this study, the median patient age was 6 years with a male predominance.  The incidence of BACM peaked in winter with a second peak in the fall.  Patients presented with prodromal symptoms including fever, cough, coryza, sore throat and vomiting.  The exam showed difficulty walking and myalgias with reproducible calf tenderness and preserved reflexes.  Influenza B and A, COVID and other viral pathogens have been detected in these patients.

Lab work may show an elevated creatinine kinase, AST and potassium.  WBC and CRP may also be elevated.  The median CK value was 943 U/L and on average normalized within one week.  Other studies have shown median CK values in the 3300s. Treatment includes hydration to promote CK clearance and prevent complications including acute kidney injury related to rhabdomyolysis.  Recurrent myositis or CK values > 5000 U/L should have screening tests for muscular dystrophy and metabolic disorders.

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Revisits back to the ED within 3 days of the initial visit represent a standard quality measure.  A critical ED revisit was defined as an ICU admission or death within 3 days of ED discharge.  This study looked at 16.3 million children who were discharged from various EDs over a 4 year period and found that 0.1% (18,704 patients) had a critical revisit and 0.00001% (180 patients) died.  

The most common diagnosis at the initial visit of those patients coming back with a critical revisit included: Upper respiratory infections, gastroenteritis/nausea/vomiting and asthma.

The most common critical revisit diagnosis were: asthma, pneumonia, cellulitis, bronchiolitis, upper respiratory infections, respiratory failure, seizure, gastroenteritis/nausea/vomiting, appendectomy and sickle cell crisis. Among the patients who died, 48.9% were younger than 4 years. Patients with complex medical problems and patients seen at a high volume center were more likely to have a critical ED visit.

Bottom line: These ED revisits may not have been related to missed diagnosis (with the exception of appendicitis), but rather due to the natural progression of certain disease processes.  Patients with these diagnoses may benefit from careful reassessment, targeted patient education, more specific return precautions and closer outpatient follow up.

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