Garth Meckler

Fever and neutropenia in pediatric patients with cancer.

Aggressive treatment of childhood cancers including systemic antineoplastic and radiation therapy has secondary effects on a variety of normal cells including hematopoietic elements of the bone marrow, often causing neutropenia. Neutropenia increases the risk for serious infection and is associated with significant morbidity and mortality. The approach to the treatment of the febrile neutropenic pediatric patient has evolved considerably because high- and low-risk criteria have been defined and broad-spectrum antibiotics developed. This article reviews the concepts involved in the evaluation and management of febrile, neutropenic, pediatric cancer patients.

To Intubate or Not to Intubate? Transporting Infants on Prostaglandin E1

OBJECTIVES. The purpose of this work was to describe the pretransport and transport management of infants receiving prostaglandin E1 infusion for congenital heart disease and to compare transport complications among unintubated and electively intubated infants. METHODS. We conducted a retrospective chart review of 202 infants receiving prostaglandin E1 during transport to our facility from 2000 to 2005. Prostaglandin E1 adverse effects were described as likely or possible and transport complications as major or minor (requiring no intervention). Logistic regression was used to identify risk factors for major transport complications, and subgroup analysis compared risks among unintubated and prophylactically intubated infants. RESULTS. Sixty-four percent of infants were intubated before transport: 34% emergently before prostaglandin E1, 14% for prostaglandin E1-related adverse effects, and 11% prophylactically. Likely prostaglandin E1 adverse effects were noted in 38% of infants, including 18% with apnea. Major complications occurred during 42% of all of the transports, including 7 (10%) of 73 unintubated infants and 14 (61%) of 23 prophylactically intubated infants. After controlling for multiple factors, elective intubation was a significant predictor of major transport complications. CONCLUSIONS. Despite high rates of prostaglandin E1 adverse effects, elective intubation of infants for transport significantly increased the odds of a major transport complication. The risks of prophylactic intubation before the transport of otherwise stable infants on prostaglandin E1 must be weighed carefully against possible benefits.

Diagnostic Testing and Treatment of Pediatric Headache in the Emergency Department

OBJECTIVE To describe the variability in diagnostic testing and treatment of headaches in children presenting to the emergency department (ED) with use of a nationally representative sample. STUDY DESIGN This was a retrospective cohort study using the National Hospital Ambulatory Medical Care Survey during 2005-2009. To assess the use of evidence-based treatment, we analyzed all patients <18 years old in 2 groups: (1) primary discharge diagnosis of headache and (2) discharge diagnosis of migraine. RESULTS Four hundred forty-eight sampled ED visits from 2005-2009 represented a national estimate of 1.7 million visits with a discharge diagnosis of headache. A total of 95 visits represented a national estimate of 340 000 visits with a discharge diagnosis of migraine. Median age was 13.1 years and 60% were female with a primary diagnosis of headache. In this group, neuroimaging was performed in 37% of patients and 39% underwent blood tests. Nonsteroidal anti-inflammatory drugs and opioids were most commonly used for treatment. For children with a discharge diagnosis of migraine, approximately 40% of patients received non-evidence-based treatment, most commonly with opioid medications, and >20% of patients underwent computed tomography scanning. CONCLUSIONS There is significant variability in the evaluation and treatment of pediatric headache in the ED. Despite evidence-based clinical guidelines for migraine headache, a large number of children continue to receive opioids and ionizing radiation in the ED.

Understanding Safety in Prehospital Emergency Medical Services for Children

Abstract Objective. For over a decade, the field of medicine has recognized the importance of studying and designing strategies to prevent safety issues in hospitals and clinics. However, there has been less focus on understanding safety in prehospital emergency medical services (EMS), particularly in regard to children. Roughly 27.7 million (or 27%) of the annual emergency department visits are by children under the age of 19, and about 2 million of these children reach the hospital via EMS. This paper adds to our qualitative understanding of the nature and contributors to safety events in the prehospital emergency care of children. Methods. We conducted four 8- to 12-person focus groups among paid and volunteer EMS providers to understand 1) patient safety issues that occur in the prehospital care of children, and 2) factors that contribute to these safety issues (e.g., patient, family, systems, environmental, or individual provider factors). Focus groups were conducted in rural and urban settings. Interview transcripts were coded for overarching themes. Results. Key factors and themes identified in the analysis were grouped into categories using an ecological approach that distinguishes between systems, team, child and family, and individual provider level contributors. At the systems level, focus group participants cited challenges such as lack of appropriately sized equipment or standardized pediatric medication dosages, insufficient human resources, limited pediatric training and experience, and aspects of emergency medical services culture. EMS team level factors centered on communication with other EMS providers (both prehospital and hospital). Family and child factors included communication barriers and challenging clinical situations or scene characteristics. Finally, focus group participants highlighted a range of provider level factors, including heightened levels of anxiety, insufficient experience and training with children, and errors in assessment and decision making. Conclusions. The findings of our study suggest that, just as in hospital medicine, factors at the systems, team, child/family, and individual provider level system contribute to errors in prehospital emergency care. These factors may be modifiable through interventions and systems improvements. Future studies are needed to ascertain the generalizability of these findings and further refine the underlying mechanisms.

Low-Dose Propofol for the Abortive Treatment of Pediatric Migraine in the Emergency Department

Objective Limited progress has been made in the past decade for abortive treatment of migraine headache in the pediatric emergency department (PED). Propofol, a general anesthetic, has been reported to be effective in the treatment of refractory headaches in adults at subanesthetic doses but never in the pediatric population. The goal of this study was to review our institution’s experience with subanesthetic doses of propofol for the abortive treatment of pediatric migraine and compare propofol with standard abortive therapy in the PED. Methods Retrospective review of all patients discharged from the Oregon Health and Science University PED with a diagnosis of migraine headache from January 2010 to July 2011. Patients treated with subanesthetic doses of propofol were compared with matched controls who received standard abortive migraine therapy, defined as the combined use of a nonsteroidal anti-inflammatory medication, diphenhydramine, and prochlorperazine. Outcome variables of interest included reduction of pain as measured on a self-reported visual analog scale and length of stay after administration of initial abortive medication. Results Patients who received subanesthetic doses of propofol achieved significantly greater reduction in pain scores (80.1% vs 61.1%; P < 0.05) compared with matched controls as well as shorter stay (122 minutes vs 203 minutes; P = 0.2) after treatment. No adverse effects (hypotension, respiratory depression, or hypoxia) were recorded in either group. Conclusions Propofol seems to be effective for the abortive treatment of pediatric migraine headache in the PED. Further prospective trials are warranted to either support or refute these initial findings.

Pediatric Educational Needs Assessment for Urban and Rural Emergency Medical Technicians

Objective The objective of the study was to identify past experiences, present needs, barriers, and desired methods of training for urban and rural emergency medical technicians. Methods This 62-question pilot-tested written survey was administered at the 2008 Oregon EMS and 2009 EMS for Children conferences. Respondents were compared with registration lists and the state emergency medical services (EMS) database to assess for nonresponder bias. Agencies more than 10 miles from a population of 40,000 were defined as rural. Results Two hundred nineteen (70%) of 313 EMS personnel returned the surveys. Respondents were 3% first responders, 27% emergency medical technician basics, 20% intermediates, and 47% paramedics. Sixty-eight percent were rural, and 32% were urban. Sixty-eight percent reported fewer than 10% pediatric transports. Overall, respondents rated their comfort caring for pediatric patients as 3.1 on a 5-point Likert scale (95% confidence interval, 3.1–3.2). Seventy-two percent reported a mean rating of less than “comfortable” (4 on the scale) across 17 topics in pediatric care, which did not differ by certification level. Seven percent reported no pediatric training in the last 2 years, and 76% desired more. The “quality of available trainings” was ranked as the most important barrier to training; 26% of rural versus 7% of urban EMS personnel ranked distance as the most significant barrier (P < 0.01). Fifty-one percent identified highly realistic simulations as the method that helped them learn best. In the past 2 years, 19% had trained on a highly realistic pediatric simulator. One to 3 hours was the preferred duration for trainings. Conclusions Except for distance as a barrier, there were no significant differences between urban and rural responses. Both urban and rural providers desire resources, in particular, highly realistic simulation, to address the infrequency of pediatric transports and limited training.

Children's Safety Initiative: A National Assessment of Pediatric Educational Needs among Emergency Medical Services Providers

Abstract Objective. Emergency medical services (EMS) providers may have critical knowledge gaps in pediatric care due to lack of exposure and training. There is currently little evidence to guide educators to the knowledge gaps that most need to be addressed to improve patient safety. The objective of this study was to identify educational needs of EMS providers related to pediatric care in various domains in order to inform development of curricula. Methods. The Childrens Safety Initiative-EMS performed a three-phase Delphi survey on patient safety in pediatric emergencies among providers and content experts in pediatric emergency care, including physicians, nurses, and prehospital providers of all levels. Each round included questions related to educational needs of providers or the effect of training on patient safety events. We identified knowledge gaps in the following domains: case exposure, competency and knowledge, assessment and decision making, and critical thinking and proficiency. Individual knowledge gaps were ranked by portion of respondents who ranked them “highly likely” (Likert-type score 7–10 out of 10) to contribute to safety events. Results. There were 737 respondents who were included in analysis of the first phase of the survey. Paramedics were 50.8% of respondents, EMT-basics/first responders were 22%, and physicians 11.4%. The top educational priorities identified in the final round of the survey include pediatric airway management, responder anxiety when working with children, and general pediatric skills among providers. The top three needs in decision-making include knowing when to alter plans mid-course, knowing when to perform an advanced airway, and assessing pain in children. The top 3 technical or procedural skills needs were pediatric advanced airway, neonatal resuscitation, and intravenous/intraosseous access. For neonates, specific educational needs identified included knowing appropriate vital signs and preventing hypothermia. Conclusions. This is the first large-scale Delphi survey related to pediatric prehospital education. Our results provide foundational information related to the educational needs of prehospital providers. Medical directors and educators can use the results to shape future curricular development.

The association between hospital type and mortality among critically ill children in US EDs

STUDY AIM Little is known about the setting of care for critically ill children and whether differences in outcomes are related to the presenting hospital type. This study describes the characteristics of hospitals to which critically ill children present and explores the associations between hospital factors and mortality. METHODS This is a retrospective cohort study using data from the 2007 Healthcare Cost and Utilization Project National Emergency Department Sample, representative of all US ED visits. Subjects include children aged 0-18 with ICD9 codes for cardiac arrest, respiratory arrest and/or respiratory failure. Predictor variables include: age, sex, presence of chronic illness, self-pay, public insurance, trauma diagnosis, major trauma center, urban hospital, ED volume and teaching hospital. Multivariate logistic regression estimates predictors of mortality. Analyses integrate clusters, strata, and weights from the probability sample. RESULTS There were an estimated 29 million pediatric ED visits in 2007 including 42,036 (0.1%) visits for cardiac or respiratory failure. Teaching hospitals (OR 0.57, 95% CI 0.50-0.66), trauma centers (OR 0.76, 95% CI 0.67-0.86), and urban hospitals (OR 0.78, 95% CI 0.63-0.97) were associated with lower mortality odds. Presence of a chronic illness (OR 14.5, 95% CI 10.5-20.1), diagnosis of an injury (OR 1.2, 95% CI 1.1-1.4) and self-pay status (OR 3.6, 95% CI 2.9-4.4) were associated with increased mortality odds. CONCLUSIONS The majority of children with cardiac and respiratory arrest present to urban teaching hospitals and trauma centers. After accounting for important confounders, mortality is lower at teaching hospitals and/or major trauma centers.

Pediatric Migraine: Abortive Management in the Emergency Department

Studies suggest that headache accounts for approximately 1% of pediatric emergency department (ED) visits. ED physicians must distinguish between primary headaches, such as a tension or migraine, and secondary headaches caused by systemic disease including neoplasm, infection, or intracranial hemorrhage. A recent study found that 40% of children presenting to the ED with headache were diagnosed with a primary headache, and 75% of these were migraine. Once the diagnosis of migraine has been made, the ED physician is faced with the challenge of determining appropriate abortive treatment. This review summarizes the most recent literature on pediatric migraine with an emphasis on diagnosis and abortive treatment in the ED.

Barriers to pediatric disaster triage: a qualitative investigation.

Abstract Background. In disasters, paramedics often triage victims, including children. Little is known about obstacles paramedics face when performing pediatric disaster triage. Objective. To determine obstacles to pediatric disaster triage performance for paramedics enrolled in a simulation-based disaster curriculum. Design. We conducted a qualitative evaluation of paramedics’ self-reported obstacles to pediatric disaster triage performance. The paramedics were enrolled in a pediatric disaster triage curriculum at one of three study sites. An individually administered, semi-structured debriefing was created iteratively, and used after a 10-victim, multiple-family house fire simulation. The debriefings were audio-recorded, and transcribed. Two investigators independently analyzed the transcripts. Using grounded theory strategy, the data were analyzed via 1) immersion and coding of data, 2) clustering of codes to generate themes, and 3) theme-based generation of hypotheses. While analyzing the data, we employed peer debriefing to determine emerging codes, groups, and thematic saturation. Systematically applied data trustworthiness strategies included triangulation and member checking. Results. A total of 34 participants were debriefed, with prehospital care experience ranging from 1 to 25 years of experience. We identified several barriers to pediatric disaster triage: 1) lack of familiarity with children and their physiology, 2) challenges with triaging children with special health-care needs, 3) emotional reactions to triage situations, including a mother holding an injured/dead child, and 4) training limitations, including poor simulation fidelity. Conclusion. Paramedics report particular difficulty triaging multiple child disaster victims due to emotional obstacles, unfamiliarity with pediatric physiology, and struggles with triage rationale and efficiency.