Kathleen Brown

Joint policy statement - Guidelines for care of children in the emergency department

Children who require emergency care have unique needs, especially when emergencies are serious or life-threatening. The majority of ill and injured children are brought to community hospital emergency departments (EDs) by virtue of their geography within communities. Similarly, emergency medical services (EMS) agencies provide the bulk of out-of-hospital emergency care to children. It is imperative, therefore, that all hospital EDs have the appropriate resources (medications, equipment, policies, and education) and staff to provide effective emergency care for children. This statement outlines resources necessary to ensure that hospital EDs stand ready to care for children of all ages, from neonates to adolescents. These guidelines are consistent with the recommendations of the Institute of Medicines report on the future of emergency care in the United States health system. Although resources within emergency and trauma care systems vary locally, regionally, and nationally, it is essential that hospital ED staff and administrators and EMS systems administrators and medical directors seek to meet or exceed these guidelines in efforts to optimize the emergency care of children they serve. This statement has been endorsed by the Academic Pediatric Association, American Academy of Family Physicians, American Academy of Physician Assistants, American College of Osteopathic Emergency Physicians, American College of Surgeons, American Heart Association, American Medical Association, American Pediatric Surgical Association, Brain Injury Association of America, Child Health Corporation of America, Childrens National Medical Center, Family Voices, National Association of Childrens Hospitals and Related Institutions, National Association of EMS Physicians, National Association of Emergency Medical Technicians, National Association of State EMS Officials, National Committee for Quality Assurance, National PTA, Safe Kids USA, Society of Trauma Nurses, Society for Academic Emergency Medicine, and The Joint Commission.

Original ArticlesChanges in self-esteem in black and white girls between the ages of 9 and 14 years: The NHLBI growth and health study

Abstract Purpose: We examined changes in self-esteem and feelings of competence with physical appearance and social acceptance over approximately 5 years in 1166 white and 1213 black girls, aged 9 and 10 years at baseline. >Methods: Maturation stage and body mass index (BMI) were assessed annually. Biennially girls completed Harters Self-Perception Profile for Children. Changes were analyzed in the context of race, sexual maturation, BMI, and household income. Longitudinal regression models were used to compare trends with age in global self-worth, physical appearance, and social acceptance. Results: Mean global self-worth showed little change over ages 9–14 years in blacks ( p = 0.09) but decreased in whites ( p p p p p p values, ≤ 0.002). Adjustment for maturation stage, BMI, and household income did not alter the significance or direction of racial differences in the changes with age in global self-worth and physical appearance scores. Self-worth, physical appearance, and social acceptance scores decreased with increasing BMI. Decreases in physical appearance and social acceptance scores with increasing BMI were smaller in blacks than in whites ( p p p = 0.08). Conclusions: This article reports the first data on self-esteem scores by age for a large population of black girls aged 9 and 14 years and concludes that self-esteem does not follow the same developmental pattern in black as in white girls. A reason for black girls higher and more stable self-worth and their greater satisfaction with their physical appearance compared to white girls may be racial differences in attitudes toward physical appearance and obesity.

The pediatrician and disaster preparedness

For decades, emergency planning for natural disasters, public health emergencies, workplace accidents, and other calamities has been the responsibility of government agencies on all levels and certain nongovernment organizations such as the American Red Cross. In the case of terrorism, however, entirely new approaches to emergency planning are under development for a variety of reasons. Terrorism preparedness is a highly specific component of general emergency preparedness. In addition to the unique pediatric issues involved in general emergency preparedness, terrorism preparedness must consider several additional issues, including the unique vulnerabilities of children to various agents as well as the limited availability of age- and weight-appropriate antidotes and treatments. Although children may respond more rapidly to therapeutic intervention, they are at the same time more susceptible to various agents and conditions and more likely to deteriorate if they are not monitored carefully. This article is designed to provide an overview of key issues for the pediatrician with respect to disaster, terrorism, and public health emergency preparedness. It is not intended to be a complete compendium of didactic content but rather offers an approach to what pediatricians need to know and how pediatricians must lend their expertise to enhance preparedness in every community. To become fully and optimally prepared, pediatricians need to become familiar with these key areas of emergency preparedness: unique aspects of children related to terrorism and other disasters; terrorism preparedness; mental health vulnerabilities and development of resiliency; managing family concerns about terrorism and disaster preparedness; office-based preparedness; hospital preparedness; community, government, and public health preparedness; and advocating for children and families in preparedness planning.

Lorazepam vs Diazepam for Pediatric Status Epilepticus: A Randomized Clinical Trial

IMPORTANCEnBenzodiazepines are considered first-line therapy for pediatric status epilepticus. Some studies suggest that lorazepam may be more effective or safer than diazepam, but lorazepam is not Food and Drug Administration approved for this indication.nnnOBJECTIVEnTo test the hypothesis that lorazepam has better efficacy and safety than diazepam for treating pediatric status epilepticus.nnnDESIGN, SETTING, AND PARTICIPANTSnThis double-blind, randomized clinical trial was conducted from March 1, 2008, to March 14, 2012. Patients aged 3 months to younger than 18 years with convulsive status epilepticus presenting to 1 of 11 US academic pediatric emergency departments were eligible. There were 273 patients; 140 randomized to diazepam and 133 to lorazepam.nnnINTERVENTIONSnPatients received either 0.2 mg/kg of diazepam or 0.1 mg/kg of lorazepam intravenously, with half this dose repeated at 5 minutes if necessary. If status epilepticus continued at 12 minutes, fosphenytoin was administered.nnnMAIN OUTCOMES AND MEASURESnThe primary efficacy outcome was cessation of status epilepticus by 10 minutes without recurrence within 30 minutes. The primary safety outcome was the performance of assisted ventilation. Secondary outcomes included rates of seizure recurrence and sedation and times to cessation of status epilepticus and return to baseline mental status. Outcomes were measured 4 hours after study medication administration.nnnRESULTSnCessation of status epilepticus for 10 minutes without recurrence within 30 minutes occurred in 101 of 140 (72.1%) in the diazepam group and 97 of 133 (72.9%) in the lorazepam group, with an absolute efficacy difference of 0.8% (95% CI, -11.4% to 9.8%). Twenty-six patients in each group required assisted ventilation (16.0% given diazepam and 17.6% given lorazepam; absolute risk difference, 1.6%; 95% CI, -9.9% to 6.8%). There were no statistically significant differences in secondary outcomes except that lorazepam patients were more likely to be sedated (66.9% vs 50%, respectively; absolute risk difference, 16.9%; 95% CI, 6.1% to 27.7%).nnnCONCLUSIONS AND RELEVANCEnAmong pediatric patients with convulsive status epilepticus, treatment with lorazepam did not result in improved efficacy or safety compared with diazepam. These findings do not support the preferential use of lorazepam for this condition.nnnTRIAL REGISTRATIONnclinicaltrials.gov Identifier: NCT00621478.

Expanding our understanding of the relationship between negative life events and depressive symptoms in black and white adolescent girls.

BACKGROUNDnLittle is known about the extent to which negative life events predict depressive symptoms in ethnically diverse groups or whether this relationship is proximal or enduring.nnnMETHODnThe relationship between negative life events in adolescence and depressive symptoms in young adulthood was studied in a sample of over 1300 black and white female adolescents. Five domains of life events were assessed at age 16 years and depressive symptoms were measured at age 18 and again at age 21 years. Questions of interest included whether the association continued over time and whether there were specific domains of life events that predicted symptoms better than others.nnnRESULTSnThe total number of negative life events at time 1 predicted depressive symptoms at both time 2 and time 3. Interpersonal loss events and other adversities, however, predicted depressive symptoms only at time 2, whereas at time 3, only interpersonal trauma was a significant predictor. No ethnic differences were found, indicating that the relationship between life events and depressive symptoms appears to be similar for black and white adolescent girls.nnnCONCLUSIONSnThe results suggest that negative life events and some specific type of stressorsincrease the likelihood of the onset of depression symptoms in future years, for both black and white girls. Early preventive efforts should be directed at adolescents who experience loss due to death of a significant other, traumatic events, and psychosocial adversities to forestall the development of depressive symptoms.

Patient- and Family-Centered Care of Children in the Emergency Department

Patient- and family-centered care is an approach to the planning, delivery, and evaluation of health care that is grounded in a mutually beneficial partnership among patients, families, and health care professionals. Providing patient- and family-centered care to children in the emergency department setting presents many opportunities and challenges. This revised technical report draws on previously published policy statements and reports, reviews the current literature, and describes the present state of practice and research regarding patient- and family-centered care for children in the emergency department setting as well as some of the complexities of providing such care.

Management of pediatric trauma

Injury is the number 1 killer of children in the United States. In 2004, injury accounted for 59.5% of all deaths in children younger than 18 years. The financial burden to society of children who survive childhood injury with disability continues to be enormous. The entire process of managing childhood injury is complex and varies by region. Only the comprehensive cooperation of a broadly diverse group of people will have a significant effect on improving the care and outcome of injured children. This statement has been endorsed by the American Association of Critical-Care Nurses, American College of Emergency Physicians, American College of Surgeons, American Pediatric Surgical Association, National Association of Childrens Hospitals and Related Institutions, National Association of State EMS Officials, and Society of Critical Care Medicine.

Point-of-care ultrasonography by pediatric emergency medicine physicians

Emergency physicians have used point-of-care ultrasonography since the 1990s. Pediatric emergency medicine physicians have more recently adopted this technology. Point-of-care ultrasonography is used for various scenarios, particularly the evaluation of soft tissue infections or blunt abdominal trauma and procedural guidance. To date, there are no published statements from national organizations specifically for pediatric emergency physicians describing the incorporation of point-of-care ultrasonography into their practice. This document outlines how pediatric emergency departments may establish a formal point-of-care ultrasonography program. This task includes appointing leaders with expertise in point-of-care ultrasonography, effectively training and credentialing physicians in the department, and providing ongoing quality assurance reviews.

Policy statement - Consent for emergency medical services for children and adolescents

Parental consent generally is required for the medical evaluation and treatment of minor children. However, children and adolescents might require evaluation of and treatment for emergency medical conditions in situations in which a parent or legal guardian is not available to provide consent or conditions under which an adolescent patient might possess the legal authority to provide consent. In general, a medical screening examination and any medical care necessary and likely to prevent imminent and significant harm to the pediatric patient with an emergency medical condition should not be withheld or delayed because of problems obtaining consent. The purpose of this policy statement is to provide guidance in those situations in which parental consent is not readily available, in which parental consent is not necessary, or in which parental refusal of consent places a child at risk of significant harm.

Effectiveness of a clinical pathway for the emergency treatment of patients with inborn errors of metabolism.

OBJECTIVE. The goal was to measure the effectiveness of a clinical pathway for the emergency department care of patients with inborn errors of metabolism. METHODS. Two years after the implementation of a multidisciplinary clinical pathway for patients with inborn errors of metabolism in our urban, academic, pediatric emergency department, we compared measures of timeliness and effectiveness for patients treated before the pathway with the same measures for patients treated after implementation of the pathway. Measures of timeliness included time to room, time to doctor, time to glucose infusion, and total emergency department length of stay. Measures of clinical effectiveness included the proportion of patients receiving adequate glucose infusions, proportion of patients admitted, inpatient length of stay, and proportion of patients requiring PICU admission. RESULTS. A total of 214 emergency department visits for patients with inborn errors of metabolism were analyzed, 90 before and 124 after initiation of the pathway. All measures of timeliness of care except total emergency department length of stay demonstrated significant improvement in comparisons of values before and after initiation of the pathway. Measures of clinical effectiveness also demonstrated significant improvements after initiation of the pathway. There was improvement in the proportion of patients who received adequate glucose infusions, with a decrease in the proportion of patients who required admission to the PICU. Emergency department length of stay, inpatient length of stay, and the proportion of patients admitted to the hospital were not affected. CONCLUSIONS. Most measures of timeliness and 2 measures of effectiveness showed improvement after implementation of an emergency department pathway for patients with inborn errors of metabolism. Therefore, a clinical pathway can improve the emergency care of patients with inborn errors of metabolism.