Category: EMS
Keywords: vital signs, age, pediatric, prehospital intervention (PubMed Search)
Posted: 2/21/2024 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
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.
Ramgopal S, Sepanski RJ, Crowe RP, Martin-Gill C. External validation of empirically derived vital signs in children and comparison to other vital signs classification criteria [published online ahead of print, 2023 Apr 27]. Prehosp Emerg Care. 2023;1-15. doi:10.1080/10903127.2023.2206473
Category: Pediatrics
Keywords: myositis, acute kidney injury, problems walking, calf pain (PubMed Search)
Posted: 2/14/2024 by Jenny Guyther, MD
(Updated: 2/16/2024)
Click here to contact Jenny Guyther, MD
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.
Attainaese et al. Benign acute children myositis: 5 year experience in a tertiary pediatric hospital. European Journal of Pediatrics, published online July 18 2023.
Category: Pediatrics
Keywords: Bouncebacks, high risk discharges, gastroenteritis, death (PubMed Search)
Posted: 1/19/2024 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
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.
Cavallaro et al. Critical Revisits Among Children After Emergency Department Discharge. Annals of Emergency Medicine. 2023. epub ahead of print.
Category: EMS
Keywords: ACS, PE, risk stratification (PubMed Search)
Posted: 1/17/2024 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
The 2nd most common reason for EMS activation is chest pain. In this study, paramedics were asked to complete the HEAR (history, EKG, age, risk factor) score, EDACS (ED Assessment of chest pain score), the Revised Geneva Score and the PERC (Pulmonary embolism rule-out criteria) for all patients older than 21 who presented with chest pain. The positive and negative likelihood ratios (LR) of the risk scores in relation to 30 day MACE and PE risk were calculated.
837 patients were included in this study with 687 patients having all 4 scores completed. The combination of HEAR/PERC had the best negative LR (0.25) for ruling our MACE and PE at 30 days. However, these scores, alone or in combination, were not sufficient to exclusively guide treatment or destination decisions. Adding biomarkers (ie troponin or Ddimer to the prehospital setting) could improve the usefulness of these scores.
Stopyra JP, Snavely AC, Ashburn NP, et al. Performance of Prehospital Use of Chest Pain Risk Stratification Tools: The RESCUE Study. Prehosp Emerg Care. 2023;27(4):482-487. doi:10.1080/10903127.2022.2036883
Category: EMS
Keywords: EMS, red, yellow, divert, capacity (PubMed Search)
Posted: 12/20/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
US hospitals have traditionally been concerned that without an ambulance diversion protocol that they would be overrun with EMS arrivals. EMS had been concerned that without diversion there would be extended wait times at the hospital. This study looked at EMS arrivals one year (2021) before the elimination of diversion and compared the number to one year after diversion elimination (2022).
This study of a single level 1 trauma center showed that there was NO difference between the number of EMS arrivals per day (84 vs 83, p = 0.08), time to room for ESI 2 patients, time to head CT in acute stroke patients OR ambulance turn around time (16 min vs 17 min, p = 0.15).
Aaron M. Burnett, Kari B. Haley, Matthew F. Milder, Bjorn K. Peterson, Joey Duren, Andrew Stevens, Danielle M. Hermes, Paul Nystrom, Joseph Lippert, Jennifer L. Moberg & Kurt M. Isenberger (2023) Elimination of Emergency Department Ambulance Divert during the COVID-19 Pandemic Was Not Associated with an Increase in the Average Number of Ambulance Arrivals per Day, Prehospital Emergency Care, DOI: 10.1080/10903127.2023.2271567
Category: Pediatrics
Keywords: fever, SBI, infants (PubMed Search)
Posted: 12/15/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Urinary tract infection (UTI) is the leading cause of fever without a source in infants younger than 3 months. This data was collected from patients who presented to the emergency department with fever without a source over a 16 year period. Out of 2850 patients, 20.8% were diagnosed with a UTI, the majority of which grew E coli. Of those patients who were diagnosed with UTI, these patients were more likely to have a history of renal/GU problems, have a fever of at least 39C (38% vs 29%) or poor feeding (13% vs 8.7%). However, 48% had none of these risk factors. Also 6.1% of patients with a febrile UTI had another invasive bacterial infection. These patients were more likely to be < 1 month, be "irritable" per parents and have an elevated procalcitonin and CRP.
Bottom line: A lack of risk factors can not exclude a UTI in febrile infants < 3 months. A diagnosis of UTI also does not definitively exclude an additional invasive bacterial infection in a subset of these children.
Lejarzegi, Ainara MD*; Fernandez-Uria, Amaia MD*; Gomez, Borja MD, PhD*; Velasco, Roberto MD, PhD†; Benito, Javier MD, PhD*; Mintegi, Santiago MD, PhD*. Febrile Urinary Tract Infection in Infants Less Than 3 Months of Age. The Pediatric Infectious Disease Journal ():10.1097/INF.0000000000003947, April 24, 2023. | DOI: 10.1097/INF.0000000000003947
Category: Pediatrics
Keywords: pediatric trauma, transport, time to destination (PubMed Search)
Posted: 11/17/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Hosseinpour H. Interfacility Transfer of Pediatric Trauma to Higher Levels of Care: The Effect of Transfer Time and Level of Receiving Trauma Care. Journal of Trauma and Acute Care Surgery. Epub ahead of print.
Category: EMS
Keywords: mental health, excited delirium, agitation, sedation, ketamine (PubMed Search)
Posted: 11/15/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Bourke et al. Acute Severe Behavioral Disturbance Requiring Parenteral Sedation in Pediatric Mental Health Presentations to Emergency Medical Services: A Retrospective Chart Review. Annals of Emergency Medicine. 2023; 1-13. epub ahead of print.
Category: Pediatrics
Keywords: trauma arrest, ROSC, blunt, penetrating (PubMed Search)
Posted: 10/20/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Selesner L, Yorkgitis B, Martin M, et al. Emergency department thoracotomy in children: A Pediatric Trauma Society, Western Trauma Association, and Eastern Association for the Surgery of Trauma systematic review and practice management guideline. J Trauma Acute Care Surg. 2023;95(3):432-441. doi:10.1097/TA.
Category: EMS
Keywords: BVM, tidal volume, TV, ALS, BLS (PubMed Search)
Posted: 10/18/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
The typical bag valve mask ventilator (BVM) for adults has a reservoir volume between 1500-2000 mL depending on the manufacturer while the volume is between 500-1000 mL for a pediatric BVM. When trying to obtain the recommended tidal volume of 6-8 mL/kg (500-600 mL for the typical adult), one thought was that a pediatric BVM could be used with adult patients so as to avoid iatrogenic barotrauma. This has been studied on manakins using an oral pharyngeal airway, supraglottic airway and endotracheal tubes (ETT) and has been successful. This study attempted to obtain the same results in the back of a moving ambulance. Paramedics and EMTs, squeezing pediatric and adult BVMs with one hand, bagged adult manakins in the back of a moving ambulance (without lights and sirens). The average tidal volume was recorded using various types of airways (i-gel, King airway and ETT).
Volumes delivered with the pediatric BVM were significantly lower than the tidal volumes with adult BVMs across all airway types suggesting that in the moving ambulance, using pediatric BVMs on an adult patient would not be appropriate.
The I-Gel and King airway provided similar tidal volumes which were not statistically different than volume delivered through the ETT.
EMTs consistently delivered 50% less tidal volumes compared to paramedics. The authors suggested that perhaps the additional training and pathophysiology knowledge that paramedics have could also be important with a skill that is considered basic.
Sun et al. Are Pediatric Manual Resuscitators Only Fit for Pediatric Use? A Comparison of Ventilation Volumes in a Moving Ambulance. Prehospital Emergency Care 2023, 27:4, 501-505.
Category: EMS
Keywords: cardiac arrest, CPR, bystander (PubMed Search)
Posted: 9/20/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Ko YC, Hsieh MJ, Schnaubelt S, Matsuyama T, Cheng A, Greif R. Disparities in layperson resuscitation education: A scoping review [published online ahead of print, 2023 Jul 25]. Am J Emerg Med. 2023;72:137-146. doi:10.1016/j.ajem.2023.07.033
Category: Pediatrics
Keywords: Spontaneous Pneumomediastinum, asthma, crepitus, esophagram (PubMed Search)
Posted: 9/15/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
Roby K, Barkach C, Studzinski D, Novotny N, Akay B, Brahmamdam P. Spontaneous Pneumomediastinum is Not Associated With Esophageal Perforation: Results From a Retrospective, Case-Control Study in a Pediatric Population [published online ahead of print, 2023 Apr 23]. Clin Pediatr (Phila). 2023;99228231166997. doi:10.1177/00099228231166997
Category: Pediatrics
Keywords: Drowning, near drowning, CXR (PubMed Search)
Posted: 8/18/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
This was a retrospective study involving several hospitals in Italy. 135 patients who had drowned (the term used in the article) were included. 4.5% of patients died. Most drowning occurred in July and August. The most common comorbidity was epilepsy in about 10% of patients. Several patients were also witnessed to have trauma and syncope. Early resuscitation, either by bystanders or trained professionals, was paramount in survival.
Children who are conscious at presentation and have mild or no respiratory distress have the best prognosis. A well appearing child should be observed for 6-8 hours, given that 98% of children will present with symptoms within the first 7 hours. A chest xray is not indicated in the asymptomatic patient. Patients who are submerged greater than 25 minutes or without ROSC after 30 minutes have a poor prognosis.
Bottom line: Never swim alone and everyone should be trained in bystander CPR.
Category: EMS
Keywords: Hands only CPR, bystander CPR, directions (PubMed Search)
Posted: 8/16/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Bystander CPR increases out-of-hospital CPR survival and direction by 911 telecommunicators increases the frequency of bystander CPR. The majority of 911 centers use Medical Priority Dispatch System which walks 911 telecommunicators through a series of questions that give different instructions based on the caller's answers. Studies have shown out-of-hospital cardiac arrests are only recognized between 79-92% of the time and telecommunicator instructions for CPR can take between 176-285 seconds.
This study reviewed recorded 911 calls of patients who were found to be in cardiac arrest. Calls where the caller was not with the patient and confirmed overdoses were some of the call types that were excluded.
Out of 65 reviewed calls, 28% were not recognized during the actual call. When they were reviewed, 8/18 of the calls were deemed to be recognizable. Themes that were noted were: incomplete or delayed recognition assessment (ie uncertainty in breathing), communication gaps (callers were confused with instructions or questions), caller emotional distress, delayed repositioning for chest compressions, non essential questions and assessments, and caller refusal/hesitation or inability to act.
Bottom line: In addition to bystander CPR training, education on the process and questions involved in calling 911 could be helpful in an emergency.
Missel et al. Barriers to the Initiation of Telecommunicator-CPR during 911 Out-of-Hospital Cardiac Arrest Calls: A Qualitative Study. 2023. Prehospital Emergency Care.
Category: Pediatrics
Keywords: fever, limp, bacteremia, osteomyelitis, septic joint (PubMed Search)
Posted: 7/21/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
El Helou R, Landschaft A, Harper MB, Kimia AA. Bacteremia in Children With Fever and Acute Lower Extremity Pain [published online ahead of print, 2023 Apr 4]. Pediatrics. 2023;e2022059504. doi:10.1542/peds.2022-059504
Category: EMS
Keywords: handoff, communication, adverse outcomes (PubMed Search)
Posted: 7/19/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
Sumner BD, Grimsley EA, Cochrane NH, et al. Videographic Assessment of the Quality of EMS to ED Handoff Communication During Pediatric Resuscitations. Prehosp Emerg Care. 2019;23(1):15-21. doi:10.1080/10903127.2018.
Category: Pediatrics
Keywords: burns, pediatric (PubMed Search)
Posted: 7/7/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Kliegman, R. M., MD, Stanton, B. F., MD, St Geme, J., MD, & Schor, N. F., MD PhD. (2015). Nelson Textbook of Pediatrics (20th ed.). Elsevier Health Sciences.
Category: EMS
Keywords: ambulance, crash, response, fatality, collision (PubMed Search)
Posted: 6/22/2023 by Jenny Guyther, MD
Click here to contact Jenny Guyther, MD
Prehosp Emerg Care. 2023;27(4):455-464. doi:10.1080/10903127.2022.
Category: Pediatrics
Keywords: neonatal fever, cellulitis, bacteremia (PubMed Search)
Posted: 6/16/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Kaplin, Ron. Clinical Presentation and Approach to Evaluation and Management. Pediatric Emergency Care 2023; 39(3):188-189.
Category: Pediatrics
Keywords: IV, EMS, transfer, pediatrics (PubMed Search)
Posted: 5/19/2023 by Jenny Guyther, MD
(Updated: 2/15/2025)
Click here to contact Jenny Guyther, MD
Mangus CW, Canares T, Klein BL, et al. Interhospital Transport of Children With Peripheral Venous Catheters by Private Vehicle: A Mixed Methods Assessment. Pediatr Emerg Care. 2022;38(1):e105-e110. doi:10.1097/PEC.