CJEM Articles: pediatric
Displaying 1-10 of 15 results
Bedside emergency department ultrasonography availability and use for blunt abdominal trauma in Canadian pediatric centresJanuary 2012 14 1Christine Meyers, Joe Nemeth, Robin Cardamore
To quantify the current availability and use of bedside emergency department ultrasonography (EDUS) for blunt trauma at Canadian pediatric centres and to identify any perceived barriers to the use of bedside EDUS in such centres.
An electronic survey was sent to 162 pediatric emergency physicians and 12 site directors from the 12 pediatric emergency departments across Canada.
Ninety-two percent (11 of 12) of centres completed the survey. The individual physician response rate was 65% (106 of 162), with 100% of site directors responding. Ultrasound machines were available in 45% (5 of 11) of centres. Forty-two percent (32 of 77) of emergency physicians working in equipped pediatric centres used bedside EDUS to evaluate blunt abdominal trauma (BAT). In the subgroup of staff who also worked at adults sites, the frequency of ultrasonography use for the evaluation of pediatric BAT was 75%. In the 55% (6 of 11) of centres without ultrasonography, 88% of staff intend to incorporate its use in the future and 81% indicated that they believed the incorporation of ultrasonography would have a positive impact on patient care. The main perceived barriers to the use of ultrasonography in the evaluation of BAT were a lack of training (41%) and a lack of equipment (26%).
Bedside EDUS is currently used in almost half of pediatric trauma centres, a frequency that is significantly lower than adult centres. Physicians in pediatric centres who use ultrasonography report that it has a high utility, and a great majority of physicians at pediatric centres without EDUS plan to incorporate it in the future. The main reported barriers to its use are a lack of training and a lack of equipment availability.
Practice variability in the management of complex febrile seizures by pediatric emergency physicians and fellowsMay 2011 13 3Blake Bulloch, Justin W. Sales, Mark A. Hostetler
Objective: Febrile seizures are the most common type of childhood seizure and are categorized as simple or complex. Complex febrile seizures (CFSs) are defined as events that are focal, prolonged (> 15 minutes), or recurrent. The management of CFS is poorly defined. The objective of this study was to determine the degree of variability in the emergency department evaluation of children with CFSs.
Methods: An online survey questionnaire was developed and sent to physicians identified via the listserv of the emergency medicine section of the American Academy of Pediatrics and the pediatric emergency medicine discussion list. The questionnaire consisted of five hypothetical case vignettes describing children under 5 years of age presenting with a CFS. Following review of the first four vignettes, participants were asked if they would (1) obtain blood and urine for evaluation; (2) perform a lumbar puncture; (3) perform neurologic imaging while the child was in the emergency department; (4) admit the child to the hospital; or (5) discharge with follow-up as an outpatient, with either the primary care provider or a neurologist. The final vignette determined if antiepileptic medication would be prescribed by the physician on discharge.
Results: Of the 353 physicians who participated, 293 (83%) were pediatric emergency medicine attending physicians and 60 (17%) were pediatric emergency medicine fellows. Overall, 54% of participants indicated that they would obtain blood for evaluation, 62% would obtain urine, 34% would perform a lumbar puncture, and 36% would perform neurologic imaging. The overall hypothetical admission rate for the case vignettes was 42%.
Conclusions: This study indicates that extensive variability exists in the emergency department approach to patients with CFS. Our findings suggest that optimal management for CFS remains unclear and support the potential benefit of future prospective studies on this subject.
David Johnson, Josephine Ho, Renee Jackson
We describe the course of a toddler who ingested a massive amount of levothyroxine and review treatment options for such overdoses. A 2½-year-old boy presented shortly after an ingestion of up to 7.6 mg of levothyroxine (potentially as much as 700 μg/kg). He was initially asymptomatic, treated with oral charcoal 1 g/kg, and discharged home from the emergency department after a few hours. He returned approximately 24 hours later with a temperature of 38.5°C, heart rate of 163 beats per minute, respiratory rate of 30 breaths per minute, and blood pressure of 136/70 mm Hg. He had a slightly decreased appetite and no signs or symptoms of infection. He was admitted to hospital and treated with oral acetaminophen. The initial free thyroxine (T4) was > 100 pmol/L and free triiodothyronine (T3) was 35.3 pmol/L. The patient had desquamation of the palms and soles, hair loss, and irritability during the month following the ingestion. Resolution of the elevated free T4 occurred by 12 days post-ingestion and normalization of the thyroid-stimulating hormone by 7 weeks post-ingestion. There were no long-term sequelae. Levothyroxine overdose can result in significant complications, including seizures and arrhythmias, both of which should be monitored for. However, as our case illustrates, massive ingestion of levothyroxine in children typically follows a benign course.
Amy C. Plint, Kathryn N. Suh, Ken J. Farion, Nicholas J. Barrowman, Sarah M. Reid, Tobey Audcent
Objective: Numerous barriers to maintaining infection control practices through the use of personal protective equipment (PPE) exist in the emergency department (ED). This study examined the knowledge, self-reported behaviours, and barriers to compliance with infection control practices and the use of PPE in Canadian pediatric EDs.
Methods: A self-administered survey instrument consisting of 21 questions was developed and piloted for this study. The survey was mailed to all individuals listed in the Pediatric Emergency Research Canada database of physicians practicing pediatric emergency medicine in Canada.
Results: A total of 186 physicians were surveyed, and 123 (66%) participated. Twenty-two percent of participants reported that they had never received PPE training and 32% had not been trained in the previous 2 years. Fifty-three percent reported being very or somewhat comfortable with their knowledge of transmission-based isolation practices. Participants were correct on a mean of 4.9 of 11 knowledge-based questions (SD 1.7). For scenarios assessing self-reported use of PPE, participants selected answers that reflected PPE use in accordance with national infection control standards in a mean of 1.0 of 6 scenarios (SD 1.0). Participants reported that they would be more likely to use PPE if patients were clearly identified prior to physician assessment, equipment was accessible, and PPE use was made a priority in their ED.
Conclusions: Knowledge and self-reported adherence to recommended infection control practices among Canadian pediatric emergency physicians is suboptimal. Early identification of patients requiring PPE, convenient access to PPE, and improved education regarding isolation and PPE practices may improve adherence.
B.E. Grunau, J. Olson
Jocelyn Gravel, Michael Arsenault, Sergio Manzano
Objective: We evaluated the validity of the Canadian Paediatric Triage and Acuity Scale (PaedCTAS) for children visiting a pediatric emergency department (ED).
Methods: This was a retrospective study evaluating all children who presented to a pediatric university-affiliated ED during a 1-year period. Data were retrieved from the ED database. Information regarding triage and disposition was registered in an ED database by a clerk following patient management. In the absence of a gold standard for triage, admission to hospital, admission to pediatric intensive care unit (PICU) and length of stay (LOS) in the ED were used as surrogate markers of severity. The primary outcome measure was the correlation between triage level (from 1 to 5) and admission to hospital. The correlation between triage level and dichotomous outcomes was evaluated by a χ2 test and an analysis of variance (ANOVA) was used to evaluate the association between triage level and ED LOS.
Results: Over the 1-year period, 58 529 patients were triaged in the ED. The proportion admitted to hospital was 63% for resuscitation (level 1), 37% for emergent (level 2), 14% for urgent (level 3), 2% for semiurgent (level 4) and 1% for nonurgent (level 5) (p < 0.001). There was also a good correlation between triage levels and LOS and admission to PICU (both p < 0.001).
Conclusion: This computerized version of PaedCTAS demonstrates a strong association with admission to hospital, admission to PICU and LOS in the ED. These results suggest that PaedCTAS is a valid tool for triage of children in a pediatric ED.
Christopher E. McCoy, Laleh Gharahbaghian, Mark Langdorf, Shahram Lotfipour, Wirachin Hoonpongsimanont
This case report describes an unusual presentation of nausea, vomiting and diarrhea, which was misdiagnosed as acute gastroenteritis in a 6-year-old girl. The patient later returned to the emergency department (ED) with severe dehydration from idiopathic central diabetes insipidus (DI). At her first visit, this previously healthy patient presented with mild dehydration, signs of acute gastroenteritis and normal urine output. Her brother had experienced similar symptoms a few days earlier. She tolerated an oral fluid challenge and was discharged from the ED with stable vital signs. Two days later, the patient returned with severe dehydration, resolving diarrhea and persistent vomiting. She was admitted to the pediatric intensive care unit. Magnetic resonance imaging illustrated an absent posterior pituitary enhancing signal, which demonstrated a loss of function in that region. There were no other abnormalities. The patient subsequently received desmopressin with improving clinical status and was discharged on the eighth hospital day. DI is a rare disease, but can be fatal if left undiagnosed. It should, therefore, be considered in the differential diagnosis of a dehydrated patient with an unexpectedly low urine specific gravity.
Anna Jarvis, CTAS National Working Group, David W. Warren, Jocelyn Gravel, Louise LeBlanc
Safety of a modification of the triage level for febrile children 6 to 36 months old using the Paediatric Canadian Triage and Acuity ScaleJanuary 2008 10 1Jocelyn Gravel, Michael Arsenault, Sergio Manzano
Objective: The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) stipulates that febrile patients who are 3 to 36 months old should be triaged to the PaedCTAS 3 "urgent" category. To optimize resource use, we implemented a protocol enabling these children to be down-triaged to the PaedCTAS 4 "less urgent" category if there was no sign of toxicity. Our objective was to evaluate the safety of this triage protocol modification.
Methods: This retrospective cohort study evaluated all patients triaged in an urban tertiary pediatric hospital during a 6-month period between November 22, 2005, and May 22, 2006. Data were retrieved from the emergency department (ED) database and rates of hospitalization and intensive care unit (ICU) admission were compared for 4 groups: all patients triaged as urgent (level 3), all febrile patients from 3 to 36 months old triaged as urgent (level 3), all patients triaged as less urgent (level 4) and all febrile patients aged 3 to 36 months old who were down-triaged to less urgent (level 4).
Results: There were 36 285 total ED visits during the study period, including 3477 febrile children who were 3 to 36 months old. Nurses down-triaged 1869 febrile children (54%) to the level-4 (less urgent) category and left 1322 (38%) in the level-3 (urgent) category. Hospitalization rate for down-triaged febrile patients was similar to that seen for all PaedCTAS 4 patients (2.4% v. 2.8%, 95% confidence interval for difference -0.3% to 1.1%). Down-triaged patients had significantly lower admission rates than those remaining in the level-3 (urgent) category (absolute risk reduction 10.7% standard deviation 1.9%, p < 0.001). No down-triaged patient died or required ICU admission.
Conclusion: Febrile children aged 6 to 36 months who have no signs of toxicity can safely be down-triaged, based on triage nurse clinical judgement, to the less urgent PaedCTAS 4 category. This modification would affect the triage level of approximately 5% of all pediatric ED visits.
Mia E. Lang, Terry Klassen
Objectives: Dog bites are a common problem. The purpose of this study was to determine the characteristics of dog bites and their emergency department management in a Canadian pediatric population, and to provide treatment and prevention recommendations.
Methods: The charts of all children ≤16 years of age presenting with a dog bite to either of the 2 tertiary emergency departments in Edmonton, Alberta, between 1998 and 2002 were retrospectively reviewed.
Results: Overall, 287 cases were reviewed; 145 boys (50.5%) and 142 girls (49.5%). The mean age was 7.4 years. The patient's face was the most frequently bitten site (58.5%, n = 168), followed by an extremity (35.5%, n = 102). Most bites required sutures (54.5%, n = 155), and 72 (25.1%) were classified as severe, based on suture number (>10 sutures, n = 69), associated fractures (n = 4), operating room repair (n = 21) or fatality (n = 1). The mean age of children with severe bites was significantly lower than children with mild bites (6.3 v. 7.8 yr, p < 0.01). Most patients were treated solely in the emergency department (84.7%, n = 243); however 44 (15.3%) were admitted to hospital and required a total of 144 days of inpatient care. Signs of infection were described in 16 cases (5.6%); of these 8 had received 2 or more prior doses of antibiotics. Public health or police notification was documented in 56 cases (19.5%), and safety or preventive discussion was documented in 3 cases (1.0%).
Conclusions: Dog bites in Canadian children are common, often serious or even lethal, and not always managed ideally. Preventive discussion and public health contact is infrequently documented and likely seldom occurs. In addition to medical care, emergency department staff should provide and document preventive guidance and ensure involvement of public health or police when indicated.