Julie C. Brown

A Randomized Clinical Trial Comparing Oral, Aerosolized Intranasal, and Aerosolized Buccal Midazolam

STUDY OBJECTIVE We determine whether aerosolized intranasal or buccal midazolam reduces the distress of pediatric laceration repair compared with oral midazolam. METHODS Children aged 0.5 to 7 years and needing nonparenteral sedation for laceration repair were randomized to receive oral, aerosolized intranasal, or aerosolized buccal midazolam. Patient distress was rated by blinded review of videotapes, using the Childrens Hospital of Eastern Ontario Pain Score. Secondary outcomes included activity scores, sedation adequacy, sedation onset, satisfaction, and adverse events. RESULTS For the 169 subjects (median age 3.1 years) evaluated for the primary outcome, we found significantly less distress in the buccal midazolam group compared with the oral route group (P=.04; difference -2; 95% confidence interval -4 to 0) and a corresponding nonsignificant trend for the intranasal route (P=.08; difference -1; 95% confidence interval -3 to 1). Secondary outcomes (177 subjects) favored the intranasal group, including a greater proportion of patients with an optimal activity score (74%), a greater proportion of parents wanting this sedation in the future, and faster sedation onset. Intranasal was the route least tolerated at administration. Adverse events were similar between groups. CONCLUSION When comparing the administration of midazolam by 3 routes to facilitate pediatric laceration repair, we observed slightly less distress in the aerosolized buccal group. The intranasal route demonstrated a greater proportion of patients with optimal activity scores, greater proportions of parents wanting similar sedation in the future, and faster onset but was also the most poorly tolerated at administration. Aerosolized buccal or intranasal midazolam represents an effective and useful alternative to oral midazolam for sedation for laceration repair.

The Simulation Team Assessment Tool (STAT): Development, reliability and validation

INTRODUCTION Simulation sessions prepare medical professionals for pediatric emergencies. No validated tools exist to evaluate overall team performance. Our objective was to develop and evaluate the inter-rater reliability and validity of a team performance assessment tool during simulated pediatric resuscitations. METHODS We developed the Simulation Team Assessment Tool (STAT) which evaluated 4 domains: basic assessment skills, airway/breathing, circulation, and human factors. Scoring of each element was behaviorally anchored from 0 to 2 points. Two teams of resuscitation experts and two teams of pediatric residents performed the same simulated pediatric resuscitation. Each team was scored by six raters using the STAT. Intraclass correlation coefficients (ICC) were calculated to assess inter-rater reliability. Overall performance and domain scores between expert and resident teams were compared using repeated measures of analysis of variance to assess construct validity. RESULTS ICCs for overall performance were 0.81. Domain ICCs were: basic skills 0.73, airway/breathing skills 0.30, circulation skills 0.76, human factors 0.68. Expert versus resident average scores were: overall performance 84% vs. 66% (p=0.02), basic skills 73% vs. 55% (p<0.01); airway 80% vs. 75% (p=0.25), circulation 90% vs. 69% (p=0.02), human factors 89% vs. 66% (p=0.02). CONCLUSIONS The STATs overall performance, basic skills, circulation, and human factors domains had good to excellent inter-rater reliability, discriminating well between expert and resident teams. Similar performance in the airway/breathing domain among all teams magnified the impact of a small number of rater disagreements on the ICC. Additional study is needed to better assess the airway/breathing domain.

Lacerations and Embedded Needles Caused by Epinephrine Autoinjector Use in Children

STUDY OBJECTIVE Epinephrine autoinjector use for anaphylaxis is increasing. There are reports of digit injections because of incorrect autoinjector use, but no previous reports of lacerations, to our knowledge. We report complications of epinephrine autoinjector use in children and discuss features of these devices, and their instructions for use, and how these may contribute to injuries. METHODS We queried emergency medicine e-mail discussion lists and social media allergy groups to identify epinephrine autoinjector injuries involving children. RESULTS Twenty-two cases of epinephrine autoinjector-related injuries are described. Twenty-one occurred during intentional use for the childs allergic reaction. Seventeen children experienced lacerations. In 4 cases, the needle stuck in the childs limb. In 1 case, the device lacerated a nurses finger. The device associated with the injury was operated by health care providers (6 cases), the patients parent (12 cases, including 2 nurses), educators (3 cases), and the patient (1 case). Of the 3 epinephrine autoinjectors currently available in North America, none include instructions to immobilize the childs leg. Only 1 has a needle that self-retracts; the others have needles that remain in the thigh during the 10 seconds that the user is instructed to hold the device against the leg. Instructions do not caution against reinjection if the needle is dislodged during these 10 seconds. CONCLUSION Epinephrine autoinjectors are lifesaving devices in the management of anaphylaxis. However, some have caused lacerations and other injuries in children. Minimizing needle injection time, improving device design, and providing instructions to immobilize the leg before use may decrease the risk of these injuries.

Increase in pediatric magnet-related foreign bodies requiring emergency care.

STUDY OBJECTIVE We describe magnetic foreign body injuries among children and obtain national estimates of magnetic foreign body injury incidence over time. METHODS We searched the National Electronic Injury Surveillance System for cases of magnetic foreign bodies in children younger than 21 years in the United States, from 2002 to 2011. Cases were analyzed by location: alimentary or respiratory tract, nasal cavity, ear canal, or genital area. RESULTS We identified 893 cases of magnetic foreign bodies, corresponding to 22,581 magnetic foreign body cases during a 10-year period (95% confidence interval [CI] 17,694 to 27,469). Most magnetic foreign bodies were ingested (74%) or intranasal (21%). Mean age was 5.2 years for ingested magnetic foreign bodies and 10.1 years for nasal magnetic foreign bodies (difference 4.9; 95% CI 4.1 to 5.6), suggesting different circumstances of injury. The incidence of pediatric magnet ingestions increased from 2002 to 2003 from 0.57 cases per 100,000 children per year (95% CI 0.22 to 0.92) to a peak in 2010 to 2011 of 3.06 cases per 100,000 children per year (95% CI 2.16 to 3.96). Most ingested magnetic foreign bodies (73%) and multiple magnet ingestions (91%) occurred in 2007 or later. Patients were admitted in 15.7% of multiple magnet ingestions versus 2.3% of single magnet ingestions (difference 13.4%; 95% CI 2.8% to 24.0%). CONCLUSION Magnet-related injuries are an increasing public health problem for young children, as well for older children who may use magnets for play or to imitate piercings. Education and improved magnet safety standards may decrease the risk small magnets pose to children.

The utility of adding expiratory or decubitus chest radiographs to the radiographic evaluation of suspected pediatric airway foreign bodies.

STUDY OBJECTIVE This study aimed to compare test characteristics of standard (lateral and posteroanterior or anteroposterior) chest radiographs with and without special views (expiratory or bilateral decubitus) in the emergency department evaluation of children with suspected airway foreign bodies. METHODS From 1997 to 2008, 328 patients with a suspected airway foreign body had standard and special view chest radiographs: 192 with left and right decubitus views, 133 with expiratory views, and 3 with both. Patients were excluded for cardiorespiratory disease, chest wall deformity, visible airway foreign bodies on standard views, or spontaneously expelled airway foreign bodies. After blinded radiologist review, standard plus special view test characteristics were compared to standard views. RESULTS Nine upper airway and 70 tracheobronchial airway foreign bodies were identified by direct visualization or bronchoscopy, and the remainder were ruled out by bronchoscopy (50 patients) or clinically (199 patients). The sensitivity and specificity of the radiographs were, respectively, decubitus cohort, standard views, 56% and 79% and standard+decubitus views, 56% and 64%; expiratory radiograph cohort, standard views, 33% and 70% and standard+expiratory views, 62% and 72%. For standard plus decubitus views versus standard views alone, the relative sensitivity was 1.0 (0.56/0.56; 95% confidence interval [CI] 0.81 to 1.23) and the relative 1-specificity was 1.76 (0.36/0.21; 95% CI 1.3 to 2.37). For standard plus expiratory views versus standard views alone, the relative sensitivity was 1.87 (0.62/0.33; 95% CI 1.23 to 2.83) and the relative 1-specificity was 0.93 (0.28/0.3; 95% CI 0.6 to 1.44). CONCLUSION The addition of decubitus to standard views increases false positives without increasing true positives and lacks clinical benefit. The addition of expiratory to standard views increases true positives without increasing false positives, but test accuracy remains low and the clinical benefit is uncertain.

Hidden Attraction: A Menacing Meal of Magnets and Batteries

BACKGROUND Magnet and button battery ingestions are increasingly common, and can result in significant morbidity. Timely identification of hazardous foreign body ingestions can be difficult in non-verbal and non-disclosing children. OBJECTIVES We aim to present a case that demonstrates some of the challenges around identifying and correctly locating magnets and batteries, and the importance of prompt identification and removal. CASE REPORT We describe an older child with the covert ingestion of multiple magnets and batteries, with magnets that attracted across the stomach and a loop of jejunum. Mild symptoms and signs resulted in a delayed diagnosis and serious consequences. Radiographs suggested a gastric location of the foreign bodies. CONCLUSION Health care workers should consider the possibility of battery or magnet ingestions in children with vomiting and abdominal pain, even when well-appearing. Like esophageal batteries, multiple gastrointestinal magnets and combined magnet-battery ingestions can cause significant morbidity, and prompt identification is important. Providers should ask verbal children for ingestion histories, and consider radiographs when symptoms are atypical or persistent. Like esophageal batteries, gastrointestinal magnet-battery ingestions should be removed promptly to prevent complications. Caregivers should supervise or limit the use of toys that include magnets and batteries.

Impact of English Proficiency on Care Experiences in a Pediatric Emergency Department

OBJECTIVE To compare emergency department care experiences of Spanish-speaking, limited-English-proficient (SSLEP) and English-proficient (EP) parents and to assess how SSLEP care experiences vary by parent-perceived interpretation accuracy. METHODS The National Research Corporation Picker Institutes Family Experience Survey (FES) was administered from November 26, 2010, to July 17, 2011, to 478 EP and 152 SSLEP parents. Problem scores for 3 FES dimensions were calculated: information/education, partnership with clinicians, and access/coordination of care. Adjusted associations between language proficiency (SSLEP vs EP) and dimension problem scores were examined by multivariate Poisson regression. Unadjusted Poisson regression analysis was used to examine the association between perceived interpretation accuracy and FES problem scores for SSLEP parents who received interpretation. RESULTS SSLEP parents had a higher risk of reporting problems with access/coordination of care compared to EP parents (risk ratio 1.6, 95% confidence interval 1.2, 2.1). There were no differences in reported care experiences related to information/education or partnership with clinicians. Among SSLEP parents who received professional interpretation, those reporting poor accuracy had a higher risk of also reporting problems with information/education (risk ratio 2.1, 95% confidence interval 1.2, 3.6). CONCLUSIONS In a pediatric emergency department with around-the-clock access to professional interpretation, SSLEP parents report poorer experiences than EP parents with access/coordination of care, including perceived wait times. Their experiences with provision of information/education and partnership with clinicians approximate those of EP parents. However, SSLEP parents who perceive poor interpretation accuracy report more problems understanding information provided about their childs illness and care.

Effect of Telephone vs Video Interpretation on Parent Comprehension, Communication, and Utilization in the Pediatric Emergency Department: A Randomized Clinical Trial

IMPORTANCE Consistent professional interpretation improves communication with patients who have limited English proficiency. Remote modalities (telephone and video) have the potential for wide dissemination. OBJECTIVE To test the effect of telephone vs. video interpretation on communication during pediatric emergency care. DESIGN, SETTING, AND PARTICIPANTS Randomized trial of telephone vs. video interpretation at a free-standing, university-affiliated pediatric emergency department (ED). A convenience sample of 290 Spanish-speaking parents of pediatric ED patients with limited English proficiency were approached from February 24 through August 16, 2014, of whom 249 (85.9%) enrolled; of these, 208 (83.5%) completed the follow-up survey (91 parents in the telephone arm and 117 in the video arm). Groups did not differ significantly by consent or survey completion rate, ED factors (eg, ED crowding), child factors (eg, triage level, medical complexity), or parent factors (eg, birth country, income). Investigators were blinded to the interpretation modality during outcome ascertainment. Intention-to-treat data were analyzed August 25 to October 20, 2014. INTERVENTIONS Telephone or video interpretation for the ED visit, randomized by day. MAIN OUTCOMES AND MEASURES Parents were surveyed 1 to 7 days after the ED visit to assess communication and interpretation quality, frequency of lapses in interpreter use, and ability to name the childs diagnosis. Two blinded reviewers compared parent-reported and medical record-abstracted diagnoses and classified parent-reported diagnoses as correct, incorrect, or vague. RESULTS Among 208 parents who completed the survey, those in the video arm were more likely to name the childs diagnosis correctly than those in the telephone arm (85 of 114 [74.6%] vs. 52 of 87 [59.8%]; P = .03) and less likely to report frequent lapses in interpreter use (2 of 117 [1.7%] vs. 7 of 91 [7.7%]; P = .04). No differences were found between the video and telephone arms in parent-reported quality of communication (101 of 116 [87.1%] vs. 74 of 89 [83.1%]; P = .43) or interpretation (58 of 116 [50.0%] vs. 42 of 89 [47.2%]; P = .69). Video interpretation was more costly (per-patient mean [SD] cost,

Upper aerodigestive magnetic foreign bodies in children

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The “Superhero Cape Burrito”: A Simple and Comfortable Method of Short-term Procedural Restraint

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