Nicholas Tsarouhas

Effectiveness of intramuscular penicillin versus oral amoxicillin in the early treatment of outpatient pediatric pneumonia.

Objective: To determine if intramuscular (IM) penicillin is more effective than oral (PO) amoxicillin in the early outpatient treatment of pediatric patients with presumed bacterial pneumonia. Methods: Prospective, randomized, evaluator‐blinded, clinical trial. Setting: Pediatric emergency department (ED) of an urban childrens hospital. Patients: ED patients with radiographically confirmed pneumonias managed as outpatients. Patients with chronic illnesses, wheezing, allergy to amoxicillin or penicillin, recent antibiotic therapy, or concurrent diagnosis of another febrile illness were excluded. Interventions: Patients received either a two‐day supply of PO amoxicillin (50 mg/kg/day divided tid), or an IM injection of procaine penicillin G (PPG) (50,000 units/kg). They had a complete blood count (CBC), blood culture, and nasopharyngeal swab for viral culture done at initial visit. They returned in 24 to 36 hours for reevaluation. Outcome measures: The main measures were temperature, respiratory rate, and general appearance score; additional measures were accessory muscle use, pulse oximetry, parental report of activity/oral intake. Results: One hundred seventy patients were enrolled. There were no significant differences between the two groups at initial or follow‐up visits with respect to temperature, respiratory rate, accessory muscle use, pulse oximetry, or parental reports of activity level and oral intake. Only in the general appearance of children less than two years of age did there appear to be a difference (P = 0.03). When subanalysis excluded patients with positive viral studies (n = 17) or chest x‐rays “reread” by an attending pediatric radiologist as “no infiltrate” (n = 29), this difference disappeared (P = 0.10). Three patients in the PO group, and five in the IM group failed by all three main outcome measures (P = 1.00). Four patients in the PO group, and five in the IM group were hospitalized at the follow‐up visit (P = 1.00). Conclusion: There does not appear to be a significant difference between PO amoxicillin and IM penicillin in the early outpatient treatment of pediatric patients with presumed bacterial pneumonia.

Airway management in pediatric patients at referring hospitals compared to a receiving tertiary pediatric ICU

OBJECTIVE To describe the current practice of pediatric airway management at referring hospitals and the associated adverse events compared to a receiving tertiary pediatric ICU. METHOD Retrospective chart and transport record review of all emergency critical care transports to our Pediatric ICU over 3 years. Data regarding tracheal intubation procedure, pre-defined adverse Tracheal Intubation Associated Events (TIAEs), and airway events before, during, and after the inter-hospital transport were collected using a standard National Emergency Airway Registry for children (NEAR4KIDS) definition. Tracheal intubation outcomes were compared to in-hospital P ICU intubations. RESULTS 253/1489 (17%) of critical care transports had airway management, all by tracheal intubation. The most common condition was seizure (34%), followed by pulmonary/lower airway disease (16%). 49 (19%) had TIAEs; the most common event was mainstem bronchial intubation (13%). Incidence of TIAEs was similar to PICU (p=0.69). Thirteen had an inappropriate tracheal tube position upon PICU arrival, but none experienced accidental extubation during transport. An uncuffed tracheal tube was used in 108/172 (63%) of patients<8 years, significantly higher than PICU (20%, p<0.0001). 124 (49%) were extubated within 24 h, 153 (60%) within 48 h. Two patients had the tracheal tube changed to cuffed from uncuffed due to air leak. CONCLUSION Provider reported adverse TIAEs are common during airway management in children requiring critical care transport, but not higher compared to PICU intubations. Most inter-hospital transport patients are intubated with an uncuffed tracheal tube. Subsequent tracheal tube change from uncuffed to cuffed tube is rarely required.

Prolonged QT syndrome in children: An uncommon but potentially fatal entity☆

Prolonged QT syndrome may be either congenital, as in Jervell and Lange-Nielsen or Romano-Ward syndromes, or acquired in nature. Affected children are at risk for syncope, seizures, dysrhythmias and sudden death. Physicians should consider long QT syndrome (LQTS) in all patients who present with syncope. A thorough personal and family history should be documented, with particular attention to prior syncopal episodes, congenital deafness, and unexplained sudden death. Syncope that is either recurrent or induced by exercise or stress is concerning and also should be noted. An electrocardiogram with manual calculation of the QT interval should be performed on all patients with a suggestive history. Furthermore, the diagnosis of LQTS warrants evaluation of all other family members. With recognition and appropriate treatment of affected patients, the potentially fatal consequences of LQTS may be prevented.

Profile of Interfacility Emergency Department Transfers: Transferring Medical Providers and Reasons for Transfer.

Objectives The aim of this study was to determine the reasons for pediatric emergency department (ED) transfers and the professional characteristics of transferring providers. Methods We performed a multicenter, cross-sectional survey of ED medical providers transferring patients younger than 18 years to 1 of 4 tertiary care childrens hospitals. Referring providers completed surveys detailing the primary reasons for transfer and their medical training. Results The survey data were collected for 25 months, during which 641 medical providers completed 890 surveys, with an overall response rate of 25%. Most pediatric patients were seen by physicians (89.4%) with predominantly general emergency medicine training (64.2%). The median age of patients seen was 5.6 years. The 3 most common diagnoses were closed extremity fracture (12.2%), appendicitis (11.6%), and pneumonia (3.7%). The 3 most common reasons for transfer were need for medical/surgical subspecialist consultation (62.6%), admission to the inpatient unit (17.1%), and admission to the intensive care unit (6.5%). When asked about the need for supportive pediatric services, referring providers ranked pediatric subspecialty and pediatric inpatient unit availability as the highest. Conclusions Most pediatric interfacility ED transfers are referred by general emergency medicine physicians who often transfer for inpatient admission or subspecialty consultation. Understanding the needs of the community-based ED providers is an important step to forming more collaborative efforts for regionalized pediatric emergency care.

Improving Anaphylaxis Care: The Impact of a Clinical Pathway

By revising an ED anaphylaxis clinical pathway and decreasing the recommended length of observation, we safely reduced admissions by nearly 60% for anaphylaxis patients. BACKGROUND: Recommended durations of observation after anaphylaxis have been widely variable, with many ranging from 4 to 24 hours. Prolonged durations often prompt admission for ongoing observation. METHODS: In a multidisciplinary quality improvement initiative, we revised our emergency department (ED) anaphylaxis clinical pathway. Our primary aim was to safely decrease the recommended length of observation from 8 to 4 hours and thereby decrease unnecessary hospitalizations. Secondary aims included provider education on anaphylaxis diagnostic criteria, emphasizing epinephrine as first-line therapy, and implementing a practice of discharging ED patients with an epinephrine autoinjector in hand. The study period consisted of the 18 months before pathway revision (baseline) and the 18 months after revision. RESULTS: The overall admission rate decreased from 58.2% (106 of 182) in the baseline period to 25.3% (65 of 257) after pathway revision (P < .0001). There was no significant difference in the percentage of patients returning to the ED within 72 hours, and there were no adverse outcomes or deaths throughout the study period. After pathway revision, the median time to first epinephrine administration for the most critical patients was 10 minutes, and 85.4% (164 of 192) of patients were discharged with an epinephrine autoinjector in hand. CONCLUSIONS: By revising an anaphylaxis clinical pathway, we were able to streamline the care of patients with anaphylaxis presenting to a busy pediatric ED, without any compromise in safety. Most notably, decreasing the recommended length of observation from 8 to 4 hours resulted in a near 60% reduction in the average rate of admission.

The influence of insurance type on interfacility pediatric emergency department transfers

Background Disparities exist in the care children receive in the emergency department (ED) based on their insurance type. It is unknown if these differences exist among children transferred from outside EDs to pediatric tertiary care EDs. Objective To compare reasons for transfer and services received at pediatric tertiary care EDs between children with private and public insurance. Methods We performed a secondary analysis of a multicenter survey of ED providers transferring patients to pediatric tertiary care EDs in three major U.S. cities. Risk differences (RD) and 95% confidence intervals (CI) were calculated to compare reasons for transfer and care received at pediatric tertiary care EDs based on insurance type. Results There were 561 surveys completed by transferring providers describing reasons for transfer to pediatric tertiary care EDs with 52.2% of patients with private insurance and 47.8% with public insurance. We found no significant differences between privately and publicly insured children in reason for transfer for subspecialty consultation or need for admission. We found no significant differences in frequency of admission, radiologic studies, or ED procedures at the receiving facilities. However, a greater proportion of privately insured children had a subspecialty consultation at receiving facilities compared to publicly insured children (RD 9.7, 95% CI 2.0 to 17.4). Conclusions Transferred pediatric patients with private insurance were more likely to have subspecialty consultations than children with public insurance. Further studies are needed to better characterize the interplay between patients’ insurance type and both the request for, and the provision of, ED subspecialty consultations.

Transport of the Neonate with a Difficult/Critical Airway

Transport of the neonate with a critical airway is amongst the most challenging scenarios in the field of Transport Medicine. This chapter will review the national models of transport systems, as well as discuss best practices. It will also discuss the rules and regulations which govern interfacility transport, such as the Federal EMTALA laws. Pre-transport decision-making of the neonate with a critical airway will be carefully explored, including decisions about appropriate team compositions and modes of transport. The clinical aspects will be dissected from the time of the initial call, to the arrival of the transport team at the referring institution, to the loading of the patient for the return trip, to the actual ride back to the accepting institution. Nuances unique to rotor-wing and fixed-wing travel will be carefully explored, with special attention to altitude physiology. After reading this chapter, the reader will understand both the pre-transport factors crucial to transport planning, as well as have a firm grasp on the clinical management of the transport of a neonate with a critical airway.