Keith P. Cross

Bedside ultrasound diagnosis of nonangulated distal forearm fractures in the pediatric emergency department.

Objectives: Ultrasound (US) may be a useful tool for rapidly diagnosing fractures. Our objective was to determine the accuracy of US as compared with radiographs in the detection of nonangulated distal forearm fractures. Methods: Distal forearm US was performed and interpreted at the bedside by a pediatric emergency medicine physician before radiography in a prospective sample of children with possible nonangulated distal forearm fractures. A second pediatric emergency medicine physician with extensive US experience gave a final interpretation of the images. This second reviewer was blinded to both clinical and radiographic findings. The primary outcome was accuracy in the detection of fracture via the blinded reviewers US interpretation when compared with the radiologists clinical radiography results. Patient-reported FACES pain scores (range, 0-5) associated with both US and radiography were compared. Results: Of 101 enrolled patients, 46 had a fracture detected by the radiologist. When compared with radiographs, the blinded US interpretation had an overall accuracy of 94% (95% confidence interval [CI], 88%-99%). Sensitivity and specificity were 96% (95% CI, 85%-99%) and 93% (95% CI, 82%-98%), respectively. Positive predictive value was 92%, and negative predictive value was 96%. Mean FACES pain scores were higher following radiography than US (1.7 vs 1.2, respectively; P = 0.004). Conclusions: For the diagnosis of nonangulated distal forearm fractures in children, bedside US holds promise as a diagnostic modality, particularly with appropriate training. Ultrasound is at least no more painful that traditional radiographs. Pediatric emergency medicine physicians should consider becoming proficient in this application.

Race and Acute Abdominal Pain in a Pediatric Emergency Department

OBJECTIVE: To investigate the demographic and clinical factors of children who present to the pediatric emergency department (ED) with abdominal pain and their outcomes. METHODS: A review of the electronic medical record of patients 1 to 18 years old, who presented to the Children’s Hospital of Pittsburgh ED with a complaint of abdominal pain over the course of 2 years, was conducted. Demographic and clinical characteristics, as well as visit outcomes, were reviewed. Subjects were grouped by age, race, and gender. Results of evaluation, treatment, and clinical outcomes were compared between groups by using multivariate analysis and recursive partitioning. RESULTS: There were 9424 patient visits during the study period that met inclusion and exclusion criteria. Female gender comprised 61% of African American children compared with 52% of white children. Insurance was characterized as private for 75% of white and 37% of African American children. A diagnosis of appendicitis was present in 1.9% of African American children and 5.1% of white children. Older children were more likely to be admitted and have an operation associated with their ED visit. Appendicitis was uncommon in younger children. Constipation was commonly diagnosed. Multivariate analysis by diagnosis as well as recursive partitioning analysis did not reflect any racial differences in evaluation, treatment, or outcome. CONCLUSIONS: Constipation is the most common diagnosis in children presenting with abdominal pain. Our data demonstrate that no racial differences exist in the evaluation, treatment, and disposition of children with abdominal pain.

Predictive value of initial Glasgow coma scale score in pediatric trauma patients.

Objective The objective of this study was to determine the predictive value of the Glasgow Coma Scale (GCS) and the Glasgow Motor Component (GMC) for overall mortality, death on arrival, and major injury and the relationship between GCS and length of stay (LOS) in the emergency department (ED) and hospital. Methods Records from the American College of Surgeons National Trauma Data Base from 2007 to 2009 were extracted. Patients 0 to 18 years old transported from a trauma scene with complete initial scene data were included. Statistical analysis, including construction of receiver-operator curves, determined the correlation between GCS, GMC, and the clinical outcomes of interest. Results There were 104,035 records with complete data for analysis, including 3946 deaths. Mean patient age was 12.6 (SD, 5.5) years. Glasgow Coma Scale was predictive of overall mortality, with area under the receiver-operator curve (AUC) of 0.946 (95% confidence interval [CI], 0.941–0.951); death on arrival, with AUC of 0.958 (95% CI, 0.953–0.963); and risk of major injury, with AUC of 0.720 (0.715–0.724). Lower GCS scores were associated with shorter ED LOS and longer hospital stays (P <0.001, analysis of variance) except GCS 3, associated with shorter hospitalizations. For predicting overall mortality, the AUC for GMC was 0.940 (95% CI, 0.935–0.945), and for predicting major injury, the AUC was 0.681 (95% CI, 0.677–0.686). Conclusions For pediatric trauma victims, the GCS is predictive of mortality and injury outcomes, as well as both ED and hospital LOS, and has excellent prognostic accuracy. The GMC has predictive value for injury and mortality that is nearly equivalent to the full GCS.

Impact of ultrasound-guided femoral nerve blocks in the pediatric emergency department.

Objective The objective of this study was to compare the duration of analgesia, need for analgesic medications, and pain-related nursing interventions in patients who did and did not receive ultrasound-guided femoral nerve blocks for femur fracture pain. Methods This is a retrospective, preimplementation and postimplementation cohort study. An emergency department log of patients receiving femoral nerve blocks for femur fracture pain was compared with a similar cohort of patients with femur fractures who did not receive nerve blocks. The primary outcome is time from initial pain treatment until the next dose of analgesic. Data were analyzed using Kaplan-Meier methods. Secondary outcomes include number of doses of pain medication, total amount of morphine given, and number of pain-related nursing interventions. Data were analyzed with the Mann-Whitney U test. Results Eighty-one patients met inclusion/exclusion criteria: 50 in the preimplementation cohort and 31 in the postimplementation group. The median times until next dose of analgesic medication were 2.2 hours (interquartile range [IQR], 1.2–3.4 hours) in the preimplementation group and 6.1 hours (IQR, 3.8–9.5 hours) in the postimplementation group (P < 0.001). The median numbers of doses of pain medication were 0.3 per hour (IQR, 0.25–0.5 per hour) in the preimplementation group and 0.15 per hour (IQR, 0.07–0.3 per hour) in the postimplementation group. The median total doses of morphine were 14.8 µg/kg per hour (IQR, 9.4–19.2 µg/kg per hour) in the preimplementation group and 6.5 µg/kg per hour (IQR, 0–12.2 µg/kg per hour) in the postimplementation group (P = 0.01). The median numbers of nursing interventions were 0.4 per hour (IQR, 0.25–0.5 per hour) in the preimplementation group and 0.15 per hour (IQR, 0.1–0.2 per hour) in the postimplementation group (P < 0.001). Conclusions Patients who received ultrasound-guided femoral nerve block for femur fracture pain had longer duration of analgesia, required fewer doses of analgesic medications, and needed fewer nursing interventions than those receiving systemic analgesic medication alone.

A Better START for Low-acuity Victims: Data-driven Refinement of Mass Casualty Triage

Abstract Objective. Methods currently used to triage patients from mass casualty events have a sparse evidence basis. The objective of this project was to assess gaps of the widely used Simple Triage and Rapid Transport (START) algorithm using a large database when it is used to triage low-acuity patients. Subsequently, we developed and tested evidenced-based improvements to START. Methods. Using the National Trauma Database (NTDB), a large set of trauma victims were assigned START triage levels, which were then compared to recorded patient mortality outcomes using area under the receiver-operator curve (AUC). Subjects assigned to the “Minor/Green” level who nevertheless died prior to hospital discharge were considered mistriaged. Recursive partitioning identified factors associated with of these mistriaged patients. These factors were then used to develop candidate START models of improved triage, whose overall performance was then re-evaluated using data from the NTDB. This process of evaluating performance, identifying errors, and further adjusting candidate models was repeated iteratively. Results. The study included 322,162 subjects assigned to “Minor/Green” of which 2,046 died before hospital discharge. Age was the primary predictor of under-triage by START. Candidate models which re-assigned patients from the “Minor/Green” triage level to the “Delayed/Yellow” triage level based on age (either for patients >60 or >75), reduced mortality in the “Minor/Green” group from 0.6% to 0.1% and 0.3%, respectively. These candidate START models also showed net improvement in the AUC for predicting mortality overall and in select subgroups. Conclusion. In this research model using trauma registry data, most START under-triage errors occurred in elderly patients. Overall START accuracy was improved by placing elderly but otherwise minimally injured—mass casualty victims into a higher risk triage level. Alternatively, such patients would be candidates for closer monitoring at the scene or expedited transport ahead of other, younger “Minor/Green” victims.

Absolute lymphocyte counts as prognostic indicators for immune thrombocytopenia outcomes in children

Recent studies reviewing immune mechanisms of immune thrombocytopenia (ITP) have suggested acute and chronic forms may represent distinct immunopathological disorders. This study evaluated absolute lymphocyte counts (ALCs) as predictors for ITP outcomes.

Identifying Key Metrics for Reducing Premature Departure from the Pediatric Emergency Department

OBJECTIVES Approximately 2% to 5% of children presenting to pediatric emergency departments (PEDs) leave prior to a complete evaluation. This study assessed risk factors for premature departure (PD) from a PED to identify key metrics and cutoffs for reducing the PD rate. METHODS A 3-year cohort (June 2004-May 2007) of children presenting to a PED was evaluated. Children were excluded if they presented for psychiatric issues, were held awaiting hospital admission in the PED due to a lack of inpatient beds, were more than 21 years old, or died before disposition. Univariate analyses, multivariable logistic regression, and recursive partitioning were used to identify factors associated with PD. A fourth year of data (June 2007-May 2008) was used for validation and sensitivity analysis. RESULTS There were 132,324 patient visits in the 3-year derivation data set with a 3.8% PD rate, and 45,001 visits in the fourth-year validation data set with a 4.3% PD rate. PDs were minimized when average wait time was below 110 minutes, concurrent PDs were fewer than two, and average length of stay (LOS) was less than 224 minutes in the derivation set, with similar results in the validation set. When these metrics were exceeded, PD rates were over 10% among low-acuity patients. These findings were robust across a broad range of assumptions during sensitivity analysis. CONCLUSIONS The authors identified five key metrics associated with PD in the PED: average wait time, average LOS, acuity, concurrent PDs, and arrival rate. Operational cutoffs for these metrics, determined by recursive partitioning, may be useful to physicians and administrators when selecting specific interventions to address PDs from the PED.

Evaluating the length of stay and value of time in a pediatric emergency department with two models by comparing two different albuterol delivery systems

Abstract Objective: Asthma is one of the most common childhood illnesses and accounts for a substantial amount of pediatric emergency department visits. Historically, acute exacerbations are treated with a beta agonist via nebulizer therapy (NEB). However, with the advent of the spacer, the medication can be delivered via a metered dose inhaler (MDI + S) with the same efficacy for mild-to-moderate asthma exacerbations. To date, no study has been done to evaluate emergency department (ED) length of stay (LOS) and opportunity cost between nebulized vs MDI + S. The objective of this study was to compare ED LOS and associated opportunity cost among children who present with a mild asthma exacerbation according to the delivery mode of albuterol: MDI + S vs NEB. Methods: A structured, retrospective cross-sectional study was conducted. Medical records were reviewed from children aged 1–18 years treated at an urban pediatric ED from July 2007 to June 2008 with a discharge diagnosis International Classification of Disease-9 of asthma. Length of stay was defined: time from initial triage until the time of the guardian signature on the discharge instructions. An operational definition was used to define a mild asthma exacerbation; those patients requiring only one standard weight based albuterol treatment. Emergency department throughput time points, demographic data, treatment course, and delivery method of albuterol were recorded. Results: Three hundred and four patients were analyzed: 94 in the MDI + S group and 209 in the NEB group. Mean age in years for the MDI + S group was 9.57 vs 5.07 for the NEB group (p < 0.001). The percentage of patients that received oral corticosteroids was 39.4% in the MDI + S group vs 61.7% in the NEB group (p < 0.001). There was no difference between groups in: race, insurance status, gender, or chest radiographs. The mean ED LOS for patients in the MDI + S group was 170 minutes compared to 205 minutes in the NEB group. On average, there was a 25.1 minute time savings per patient in ED treatment time (p < 0.001; 95% CI = 3.8–31.7). Significant predictors of outcome for treatment time were chest radiograph, steroids, and treatment mode. Opportunity cost analysis estimated a potential cost savings of

Out of the frying pan, into the fire: a case of heat shock and its fatal complications

213,532 annually using MDI + S vs NEB. Conclusion: In mild asthma exacerbations, administering albuterol via MDI + S decreases ED treatment time when compared to administering nebulized albuterol. A metered dose inhaler with spacer utilization may enhance opportunity cost savings and decrease the left without being seen population with improved throughput. Limitations: The key limitations of this study include its retrospective design, the proxy non-standard definition of mild asthma exacerbation, and the opportunity cost calculation, which may over-estimate the value of ED time saved based on ED volume.

Cost-effectiveness of Strategies for Offering Influenza Vaccine in the Pediatric Emergency Department

Abstract Exertional heat stroke incidence is on the rise and has become the third leading cause of death in high school athletes. It is entirely preventable, yet this is a case of a 15-year-old, 97-kg male football player who presented unresponsive and hyperthermic after an August football practice. His blood pressure was 80/30, and his pulse was 180. He had a rectal temperature of 107.3°F, and upon entering the emergency department, he was rapidly cooled in 40 minutes. As he progressed, he developed metabolic acidosis, elevated liver enzymes, a prolapsed mitral valve with elevated troponin levels, and worsening hypotension even with extracorporeal membrane oxygenation support. After 3 days in the hospital, this young man was pronounced dead as a result of complications from exertional heat stroke. We address not only the complications of his hospital course relative to his positive blood cultures but also the complications that can result from attention-deficit/hyperactivity disorder medication our patient was taking. As the population of young adults becomes more obese and more highly medicated for attention-deficit/hyperactivity disorder, we sought out these growing trends in correlation with the increase in incidence of heat-related illness. We also address the predisposing factors that make young high school athletes more likely to experience heat illness and propose further steps to educate this susceptible population.