Getachew Teshome

Factors Associated With Cervical Spine Injury in Children After Blunt Trauma

STUDY OBJECTIVE Cervical spine injuries in children are rare. However, immobilization and imaging for potential cervical spine injury after trauma are common and are associated with adverse effects. Risk factors for cervical spine injury have been developed to safely limit immobilization and radiography in adults, but not in children. The purpose of our study is to identify risk factors associated with cervical spine injury in children after blunt trauma. METHODS We conducted a case-control study of children younger than 16 years, presenting after blunt trauma, and who received cervical spine radiographs at 17 hospitals in the Pediatric Emergency Care Applied Research Network (PECARN) between January 2000 and December 2004. Cases were children with cervical spine injury. We created 3 control groups of children free of cervical spine injury: (1) random controls, (2) age and mechanism of injury-matched controls, and (3) for cases receiving out-of-hospital emergency medical services (EMS), age-matched controls who also received EMS care. We abstracted data from 3 sources: PECARN hospital, referring hospital, and out-of-hospital patient records. We performed multiple logistic regression analyses to identify predictors of cervical spine injury and calculated the models sensitivity and specificity. RESULTS We reviewed 540 records of children with cervical spine injury and 1,060, 1,012, and 702 random, mechanism of injury, and EMS controls, respectively. In the analysis using random controls, we identified 8 factors associated with cervical spine injury: altered mental status, focal neurologic findings, neck pain, torticollis, substantial torso injury, conditions predisposing to cervical spine injury, diving, and high-risk motor vehicle crash. Having 1 or more factors was 98% (95% confidence interval 96% to 99%) sensitive and 26% (95% confidence interval 23% to 29%) specific for cervical spine injury. We identified similar risk factors in the other analyses. CONCLUSION We identified an 8-variable model for cervical spine injury in children after blunt trauma that warrants prospective refinement and validation.

Cervical spine injury patterns in children

BACKGROUND AND OBJECTIVE: Pediatric cervical spine injuries (CSIs) are rare and differ from adult CSIs. Our objective was to describe CSIs in a large, representative cohort of children. METHODS: We conducted a 5-year retrospective review of children <16 years old with CSIs at 17 Pediatric Emergency Care Applied Research Network hospitals. Investigators reviewed imaging reports and consultations to assign CSI type. We described cohort characteristics using means and frequencies and used Fisher’s exact test to compare differences between 3 age groups: <2 years, 2 to 7 years, and 8 to 15 years. We used logistic regression to explore the relationship between injury level and age and mechanism of injury and between neurologic outcome and cord involvement, injury level, age, and comorbid injuries. RESULTS: A total of 540 children with CSIs were included in the study. CSI level was associated with both age and mechanism of injury. For children <2 and 2 to 7 years old, motor vehicle crash (MVC) was the most common injury mechanism (56%, 37%). Children in these age groups more commonly injured the axial (occiput–C2) region (74%, 78%). In children 8 to 15 years old, sports accounted for as many injuries as MVCs (23%, 23%), and 53% of injuries were subaxial (C3–7). CSIs often necessitated surgical intervention (axial, 39%; subaxial, 30%) and often resulted in neurologic deficits (21%) and death (7%). Neurologic outcome was associated with cord involvement, injury level, age, and comorbid injuries. CONCLUSIONS: We demonstrated a high degree of variability of CSI patterns, treatments and outcomes in children. The rarity, variation, and morbidity of pediatric CSIs make prompt recognition and treatment critical.

Interhospital pediatric patient transfers-factors influencing rapid disposition after transfer.

Objective The objective of this study was to determine the incidence, demographics, and clinical course of pediatric patients rapidly discharged after transfer from outlying emergency departments (EDs) to a tertiary care pediatric ED (PED) with no additional diagnostic or therapeutic actions. Methods All pediatric patient charts from July 2009 to June 2010 who were transferred from 31 outlying EDs to an academic PED were reviewed for patient demographics, (age, sex, race) diagnosis, and disposition (admission, discharge). Primary outcome of interest in this study was percentage of children younger than 18 years discharged home after transfer to the tertiary care center (PED) with no additional medical or surgical procedures. Primary outcomes in terms of transferring physician ED pediatric physician versus ED nonpediatric physician (ED-NPP) and transferring hospital type were also analyzed using Fisher exact test. Results Three hundred forty-two patients transferred from outlying EDs to PED during the study period met inclusion criteria. Sixty percent (207/342) of overall transfers were in the age group 5 years or younger. Respiratory illness (27.5%) was the most common condition in all transfers. Patients transferred from EDs staffed by nonpediatric physician were more likely to be discharged home without needing additional studies or procedures. Patients transferred from EDs staffed by pediatricians were more likely to be admitted or required additional diagnostic and/or therapeutic interventions before disposition. Conclusions Pediatric patients transferred from outlying community EDs to a PED frequently required little or no additional care. Referring hospital ED type and physician training type are associated with the need for additional workup at the pediatric emergency room.

Telemedicine Applications for the Pediatric Emergency Medicine: A Review of the Current Literature.

Objective The aim of this study was to review current literature relating to telemedicine in pediatric emergency medicine including its clinical applications and challenges associated with its implementation. Methods We reviewed the literature using standard search methods in accordance with preferred reporting items for systematic reviews and meta-analysis. We included the studies done in emergency settings for all age groups and narrowed our search to the articles that are relevant to “impact on quality of care” and “patient outcome.” We also described current telemedicine uses, software, hardware, and other requirements needed for pediatric emergency applications. Results Telemedicine has a potential role in pediatric emergency medicine for real-time decision making to improve quality of care for children. Logistic and legal challenges exist for pediatric emergency medicine applications similar to its uses in other settings. Conclusions Current frameworks exist in the use of telemedicine for pediatric emergency medicine. Research is still needed to see whether clinical outcomes are improved with pediatric emergency telemedicine solutions. Practical issues regarding training, accessibility, and resource allocation should be explored as pediatric emergency telemedicine evolves.

Paediatric suicide in the USA: analysis of the National Child Death Case Reporting System

Importance Suicide is a leading cause of death among youths. The relationship between mental health, psychosocial factors and youth suicidality needs further analysis. Objective To describe paediatric suicide in the USA and the impact of mental health and substance abuse using the National Child Death Review Case Reporting System (CDR-CRS). To identify psychosocial correlates contributing to suicide and whether these factors are more common among individuals with history of mental illness or substance abuse. Design Deidentified data (CDR-CRS) from 2004 to 2012 was obtained from 29 participating states. Demographic data and psychosocial correlates, including age, gender, cause of death, history of mental illness and/or substance abuse, school concerns, previous suicide attempts and family history of suicide, were collected. Results A total of 2850 suicides were identified. Mean age was 15.6±1.9 years; (range 7–21 years) 73.6% male and 65.1% Caucasian. The leading causes of death were asphyxia (50.2%) and weapon/firearm (36.5%). Among all subjects, 25.5% had history of mental illness and 19.0% had history of substance abuse. 60.0% had no report of mental illness or substance abuse. Subjects with both mental illness and substance abuse were more likely to have school concerns (OR=4.1 (p<0.001)), previous suicide attempts (OR=4.2 (p<0.001)) and a family history of suicide (OR=3.2 (p<0.001)) compared with subjects without those characteristics. Conclusions Most suicide records in the CDR-CRS had no indication of mental illness or substance abuse. The youth with mental-illness/substance-abuse issues were more likely to have other compounding psychosocial correlates that may be warning signs of suicide.

Hemolytic anemia induced by ingestion of paradichlorobenzene mothballs.

Abstract Hemolytic anemia and methemoglobinemia are well-known adverse effects that follow ingestion of naphthalene mothballs. They are only rarely reported in association with ingestion of paradichlorobenzene mothballs. An asymptomatic boy presented to our pediatric emergency department after ingesting paradichlorobenzene mothballs. Three daysafter the ingestion, the boy returned with hemolysis and mild methemoglobinemia.

Consideration of Cost of Care in Pediatric Emergency Transfer-An Opportunity for Improvement.

Background Pediatric interhospital transfers are an economic burden to the health care, especially when deemed unnecessary. Physicians may be unaware of the cost implications of pediatric emergency transfers. A cost analysis may be relevant to reduce cost. Objective To characterize children transferred from outlying emergency departments (EDs) to pediatric ED (PED) with a specific focus on transfers who were discharged home in 12 hours or less after transfer without intervention in PED and analyze charges associated with them. Methods Charts of 352 patients (age, 0–18 years) transferred from 31 outlying EDs to PED during July 2009 to June 2010 were reviewed. Data were collected on the range, unit charge and volume of services provided in PED, length of stay, and final disposition. The average charge per patient transfer is calculated based on unit charge times total service units per 1000 patients per year and divided by 1000. Hospital charges were divided into fixed and variable. Results Of 352 patients transferred, 108 (30.7%) were admitted to pediatric inpatient service, 42 (11.9%) to intensive care; 36 (10.2%) went to the operating room, and 166 (47.2%) were discharged home. The average hospital charge per transfer was US

Ketamine Sedation After Administration of Oral Contrast: A Retrospective Cohort Study

4843. Most (89%) of the charges were fixed, and 11% were variable. One hundred one (28.7%) patients were discharged home from PED in 12 hours or less without intervention. The hospital charges for these transfers were US

Emergent diagnostic testing for pediatric nonfebrile seizures

489,143. Conclusions Significant number of transfers was discharged 12 hours or less without any additional intervention in PED. Fixed charges contribute to majority of total charges. Cost saving can be achieved by preventing unnecessary transfer.

Comparison of Dexmedetomidine With Pentobarbital for Pediatric MRI Sedation

BACKGROUND The American Academy of Pediatrics and American Society of Anesthesiologists have published consensus-based fasting guidelines intended to reduce the risk of pulmonary aspiration. The purpose of our study was to compare the rate of adverse events in patients sedated with ketamine within 2 hours of oral contrast intake to those who were nil per os (NPO). METHODS A retrospective cohort review of a database of children between July 2008 and May 2011. The rate of adverse events in children sedated with ketamine after intake of oral contrast for an abdominal computed tomography were compared with those sedated without taking oral contrast. RESULTS One hundred and four patients sedated for a computed tomography scan; 22 patients were sedated within 2 hours of taking oral contrast, and 82 were NPO. The 2 groups were comparable with regard to gender, race, and American Society of Anesthesiologists status. The mean (SD) time between the second dose of oral contrast and induction of sedation was 58 (24) minutes. Vomiting occurred in 4 of 22 patients in the oral contrast group (18%; 95% confidence interval 2%-34%) and 1 of 82 patients in the NPO group (1%; 95% confidence interval, 0%, 4%; P < .001). There was no difference in oxygen desaturation between the groups (P = .6). CONCLUSIONS Children who received oral contrast up to 58 minutes before ketamine sedation had a higher rate of vomiting than those who did not receive oral contrast. We did not identify cases of clinical aspiration, and the incidence of hypoxia between the 2 groups was not statistically significant.