Robyn Wing

Use of high-flow nasal cannula support in the emergency department reduces the need for intubation in pediatric acute respiratory insufficiency

Objectives The objective of this study was to determine whether the use of heated, humidified, high-flow nasal cannula (HFNC) therapy is associated with a decreased need for intubation in patients presenting to a pediatric emergency department (PED) and admitted to a pediatric intensive care unit (PICU) with acute respiratory insufficiency (ARI). Methods A retrospective study of all patients admitted from the PED to the PICU with ARI from January 2006 through December 2009. Patients admitted before the availability of HFNC (cohort 1) were compared with those admitted after the availability of HFNC but before implementation of an institution-wide guideline on pediatric HFNC usage (cohort 2) and those admitted after the implementation of a pediatric HFNC usage guideline (cohort 3). Results After controlling for age, month of admission, type of respiratory illness, and severity of illness, there was an 83% reduction in the odds of intubation in the PED in cohort 3 compared with cohort 1 (odds ratio, 0.17; 95% confidence interval, 0.06-0.50; P = 0.001). There was no significant change in mortality or median PICU length of stay after the introduction of HFNC. Conclusions High-flow nasal cannula used early in the development of pediatric ARI is associated with a decreased the need for intubation and mechanical ventilation.

Association between adverse childhood experiences in the home and pediatric asthma

BACKGROUND Numerous studies suggest that psychosocial factors could contribute to pediatric asthma. OBJECTIVE To examine the relation between single and cumulative adverse childhood experiences (ACEs), a measurement of household dysfunction, on parent report of lifetime asthma in children. METHODS This cross-sectional study used data from the 2011 to 2012 National Survey of Childrens Health, a nationally representative sample of children 0 to 17 years old (n = 92,472). The main exposure was parent or guardian report of 6 ACE exposures (eg, witnessing domestic violence). The relation between ACE exposures and parent-reported diagnosis of childhood asthma was examined using multivariable logistic regression after controlling for demographic, socioeconomic, and behavioral covariates. RESULTS Overall asthma prevalence was 14.6%. Exposure prevalence to any ACE was 29.2%. Increased number of ACE exposures was associated with increased odds of asthma. In the adjusted model, the odds of reporting asthma were 1.28 (95% confidence interval [CI] 1.14-1.43) for those reporting 1 ACE, 1.73 (95% CI 1.27-2.36) for those with 4 ACEs, and 1.61 (95% CI 1.15-2.26) for those with 5 or 6 ACEs compared with those with no ACE exposures. Effects were moderated by Hispanic ethnicity. Hispanic children exposed to 4 ACEs had a 4.46 times increase in lifetime asthma (95% CI 2.46-8.08); white children had a 1.19 times increase (95% CI 0.80-1.79) compared with those exposed to 0 ACE. CONCLUSION This study supports the growing evidence for the biopsychosocial model of asthma onset. Future studies should examine the association between ACEs and specific asthma-related health outcomes.

Heads Up Communication Is Key in School Nurses’ Preparedness for Facilitating “Return to Learn” Following Concussion

Background. Recent literature advocates for a school academic team, including school nurses, to support concussed students’ return to the classroom. This study aimed to assess the current understanding and practices of a sample of school nurses regarding the concept of “return to learn” in concussed students. Methods. Cross-sectional survey of New England school nurses. Results. The greatest barrier to the school nurses’ functioning within the academic rehabilitation team for students with concussion was “inadequate communication with the provider that diagnosed the concussion” (73%). Of the 151 school nurses surveyed, 19% felt that they did not have the training necessary for this role. Other barriers included “inadequate concussion training” (38%) and “inadequate time necessary to care for a student with concussion” (30%). Conclusions. By identifying specific gaps in knowledge and challenges at the school level, these results inform interdisciplinary medical teams about the importance of educating and facilitating effective “return to learn” academic plans.

Pediatric head injury and concussion.

Children with head injuries frequently present to emergency departments. Even though most of these children have minor injuries, head injury is the most common cause of traumatic deaths in pediatric patients. The pediatric GCS and decision rules for obtaining head CT imaging help the provider evaluate head-injured infants and children. The provider must be vigilant to diagnose those who have life-threatening intracranial injuries or are victims of abusive head trauma. The goal of the emergency physician is to diagnose and treat the consequences of the primary injury and to limit or prevent secondary injury.

Fever in the pediatric patient.

Fever is the most common reason that children and infants are brought to emergency departments. Emergency physicians face the challenge of quickly distinguishing benign from life-threatening conditions. The management of fever in children is guided by the patients age, immunization status, and immune status as well as the results of a careful physical examination and appropriate laboratory tests and radiographic views. In this article, the evaluation and treatment of children with fevers of known and unknown origin are described. Causes of common and dangerous conditions that include fever in their manifestation are also discussed.

Gone but Not Forgotten A Case of Respiratory Distress

A previously healthy, fully immunized, 6-year-old boy was brought to the emergency room with a 2-day history of sore throat, neck pain, tactile fever, and 1 episode of vomiting. On physical examination, he was afebrile and well-appearing. He had an injected oropharynx without tonsillar hypertrophy or exudate. A group A streptococcus rapid antigen detection test was negative, and a throat culture was performed. In the emergency department, he was treated with given acetaminophen and ondansetron, tolerated oral intake, and was discharged to home with a diagnosis of viral pharyngitis. Four hours later, the patient returned to the emergency department with cough and respiratory distress. His mother reported that he developed a high-pitched sound when he breathed and that he felt like there was something stuck in his throat. He had not eaten food since leaving the emergency department and was able to tolerate liquids with difficulty. On examination, he had a heart rate of 166, a temperature of 37.1°C, and a respiratory rate of 24. He was noted to have nasal flaring and accessory muscle use. On lung exam he had transmitted upper airway sounds. He had no stridor or wheezing. He received humidified oxygen, decadron 10 mg PO, and racemic epinephrine without improvement. A chest x-ray was normal. A lateral neck film was obtained. The patient’s respiratory distress increased and he developed inspiratory and expiratory stridor. Albuterol and atrovent nebulizer treatments were given without improvement. Laboratory tests were drawn, including a complete blood count (revealing a white blood cell count of 23 300, 74% segmented neutrophils, 20% band forms, hemoglobin 12.9 g/dL, platelets 299 000), Basic Metabolic Panel (BMP), and blood culture and ENT was consulted. The attending radiologist reviewed the lateral neck films and noted the enlargement of the epiglottis and thickening of the aryepiglottic folds. The patient received ceftriaxone and vancomycin, and he was emergently transferred to the operating room for direct laryngoscopy and intubation. In the operating room, a very swollen, beefy red epiglottis and swollen vocal cords were visualized (Figure 1). Cultures of the upper airway were obtained. He was intubated and transported to the pediatric intensive care unit for further management.