Susan J. Duffy

Treatment of pediatric migraine headaches: A randomized, double-blind trial of prochlorperazine versus ketorolac

STUDY OBJECTIVE We compare the effectiveness of intravenous ketorolac and intravenous prochlorperazine in the treatment of pediatric migraine headaches. METHODS We performed a prospective, randomized, double-blind clinical trial in 2 pediatric emergency departments (EDs) within childrens hospitals. Children aged 5 to 18 years presenting to the ED with migraine headaches were eligible for the study. Contraindications to either medication or the inability to complete the pain score resulted in exclusion. Children were randomized to receive intravenous ketorolac (0.5 mg/kg; maximum 30 mg) or intravenous prochlorperazine (0.15 mg/kg; maximum 10 mg). All children also received a normal saline solution bolus. Successful treatment was defined as a 50% or greater reduction in the Nine Faces Pain Scale score at 60 minutes. If a less than 50% improvement occurred by 60 minutes, the child received the other medication. Forty-eight-hour follow-up telephone calls were made to each family to assess recurrence and late side effects. RESULTS Sixty-two children were enrolled: 33 initially received prochlorperazine, and 29 initially received ketorolac. By 60 minutes, 16 (55.2%) of 29 of those who received ketorolac and 28 (84.8%) of 33 of those who received prochlorperazine were successfully treated (difference=30%; 95% confidence interval [CI] 8% to 52%). Fifty-six (93.3%) of the 60 children who completed the study were successfully treated by the studys conclusion. Approximately 30% of each group had a recurrence of some headache symptoms. Only 2 children reported side effects, both mild and self-limited. CONCLUSION In children, intravenous prochlorperazine is superior to intravenous ketorolac in the acute treatment of migraine headaches.

Three scenarios to teach difficult discussions in pediatric emergency medicine: sudden infant death, child abuse with domestic violence, and medication error.

Within an emergency medicine (EM) environment, the pace of clinical care delivery rarely allows time to stop and observe extended interactions between trainees and patients, or to provide feedback on communication skills. Once residency and fellowship conclude, however, these same trainees will be required to manage complicated medical and social interactions independently. In particular, unique challenges in the realm of patient-doctor interaction arise in the field of pediatric emergency medicine (PEM), with most clinical encounters involving both a child and their caregiver. Whether delivering bad news to a family or screening and managing cases of suspected child abuse, child neglect or domestic violence, many physicians report having no formal training in communicating effectively and compassionately under difficult conditions.1–4 It is imperative to consider and prepare future physicians for the emotional relationship between the (pediatric) patient and the family when caring for the family unit, especially in emergent situations and times of crisis. The occurrence of medical error presents another tremendously challenging situation for physicians and requires sophisticated communications skills. Despite clinicians’ best preventive and conscientious efforts, various elements can lead to a medical error, and the physicians involved will need to disclose and discuss the event with the family. Once again, few physicians have had formal training in managing these situations.5 To improve training in PEM physician communications during difficult discussions, we created a hybrid medical simulation program, a combination of standardized patients and high-fidelity medical simulation. The primary objective was to educate EM residents and PEM fellows on the communication skills necessary to engage in difficult discussions when caring for children in an emergency department setting. Authors will present three scenarios developed for an educational activity designed to focus on difficult discussion communication skills in PEM.

Challenges of managing pediatric mental health crises in the emergency department

Children with mental health problems are increasingly being evaluated and treated in pediatric clinical settings. This article focuses on the epidemiology, evaluation, and management of the 2 most common pediatric mental health emergencies, suicidal and homicidal/aggressive patients, as well as the equally challenging population of children with autism or other developmental disabilities.

Compliance in Rhode Island Emergency Departments With American Academy of Pediatrics Recommendations for Adolescent Sexual Assaults

OBJECTIVES. We assessed the offering of American Academy of Pediatrics–recommended tests and prophylaxes after sexual assault to adolescents who presented to Rhode Island emergency departments for 3 categories of sexual exposures: sexual assault, consensual sex, and suspected sexual abuse. PATIENTS AND METHODS. This study entailed a retrospective review of visits for adolescent sexual exposures across 11 Rhode Island emergency departments between January 1995 and June 2001. Cases were identified through billing codes. Offering of each test and prophylaxis was compared by gender, category of sexual exposure, and type of sexual assault. Multivariable linear regression models were used to identify factors associated with the offering of a greater number of tests and prophylaxes after sexual assault. RESULTS. The vast majority of emergency department visits for adolescent sexual exposures were by sexually assaulted girls (82.5%). Across the 3 sexual exposure categories, girls were offered tests and prophylaxes more often than boys (eg, chlamydia or gonorrhea testing and prophylaxis). Among sexually assaulted adolescents, 32.8% of girls and no boys were offered all recommended tests and prophylaxes. The multivariable linear regression found that vaginally and/or anally assaulted girls were offered, on average, 2.5 more tests and prophylaxes than patients with other types of sexual assaults. Girls presenting for care at the states womens health care specialty hospital emergency departments were offered 1.7 more tests and prophylaxes than those evaluated in general hospital emergency departments. CONCLUSIONS. Many adolescents did not receive American Academy of Pediatrics–recommended tests and prophylaxes after sexual assault. Boys received fewer tests than girls. Testing and prophylaxis varied by type of emergency department. Efforts are needed to improve and standardize emergency department medical management of adolescent sexual exposures.

Pediatric mental health emergencies and special health care needs.

Children with mental health problems are increasingly being evaluated and treated by both pediatric primary care and pediatric emergency physicians. This article focuses on the epidemiology, evaluation, and management of the 2 most common pediatric mental health emergencies, suicidal and homicidal/aggressive patients, as well as the equally challenging population of children with autism or other developmental disabilities.

Reflectance spectrometry of normal and bruised human skins: experiments and modeling

A stochastic photon transport model in multilayer skin tissue combined with reflectance spectroscopy measurements is used to study normal and bruised skins. The model is shown to provide a very good approximation to both normal and bruised real skin tissues by comparing experimental and simulated reflectance spectra. The sensitivity analysis of the skin reflectance spectrum to variations of skin layer thicknesses, blood oxygenation parameter and concentrations of main chromophores is performed to optimize model parameters. The reflectance spectrum of a developed bruise in a healthy adult is simulated, and the concentrations of bilirubin, blood volume fraction and blood oxygenation parameter are determined for different times as the bruise progresses. It is shown that bilirubin and blood volume fraction reach their peak values at 80 and 55 h after contusion, respectively, and the oxygenation parameter is lower than its normal value during 80 h after contusion occurred. The obtained time correlations of chromophore concentrations in developing contusions are shown to be consistent with previous studies. The developed model uses a detailed seven-layer skin approximation for contusion and allows one to obtain more biologically relevant results than those obtained with previous models using one- to three-layer skin approximations. A combination of modeling with spectroscopy measurements provides a new tool for detailed biomedical studies of human skin tissue and for age determination of contusions.

Development of a survey of teamwork and task load among medical providers: a measure of provider perceptions of teamwork when caring for critical pediatric patients.

Introduction Teamwork training focuses on improving patient outcomes through better communication. Scales exist to assess providers’ perceptions of teamwork; however, they are not designed for use immediately after the care of critically ill patients. Objectives This study aimed to develop a survey to quantify providers’ perceptions of teamwork and task load during critical care resuscitations in a PED and to use the tool to compare physician and nonphysician ratings of resuscitations. Methods Survey items were adapted from validated tools. The resulting survey contained 15 Likert scale items completed by providers immediately after resuscitations. An exploratory factor analysis was conducted. Mixed models, accounting for clustering of providers within resuscitations, tested for systematic differences in responses between physicians and nonphysicians and explored how well the factor scores predicted the overall “smoothness” of the resuscitation. Results Six hundred fifty-four surveys from 169 resuscitations were conducted. The exploratory factor analysis identified 2 factors with 13 items explaining 47% of the overall variance of “teamwork and communication” (Cronbach &agr; = 0.80) and “task load” (Cronbach &agr; = 0.77). There were no differences in factors predicting smoothness between physicians and nonphysicians (P = 0.27). Both were significant positive predictors of the outcome “the resuscitation went smoothly.” Conclusions The Survey of Teamwork and Task Load among Medical Providers was developed to evaluate providers’ perceptions of teamwork immediately after care of critically ill patients in a pediatric emergency department. Items reflect 2 constructs, with good internal consistency. Responses did not vary by professional training, suggesting that it is useful for all providers. Both factors predicted the overall smoothness. Each was useful in predicting the perception that the resuscitation went smoothly.

The association of nonaccidental trauma with historical factors, examination findings, and diagnostic testing during the initial trauma evaluation

Nonaccidental trauma (NAT) or child abuse is the deliberate or intentionally inflicted injury of a child and is a form of child maltreatment.1 One in four children experience some form of maltreatment in their lifetime.2 Annually, nearly one million children are victims of maltreatment in the UnitedEarly identification of non-accidental trauma (NAT) is a critical component of pediatric trauma care. Literature searches were conducted related to the association of NAT with seven key areas: history, exam findings (burns, oral trauma, bruising) and imaging (fractures, abdominal and brain injuries). When available, odds ratios (OR) with 95% confidence intervals (CI) for associations with NAT are presented. Systematic reviews have been published in six of the seven key areas and are described. The operational definition of NAT was widely variable across studies, prohibiting meta-analysis. Select highly associated findings included bruising in a pre-mobile child, clustering of bruises (OR 4.0, CI 2.5-6.4), petechiae (OR 9.3, CI 2.9-30.2), chemical burns 24.6 (4.94-135); contact burns 5.2 (1.6-22.9); scald burns 17.4 (6.4-72), burns to hand 1.8 (1.3-2.6), feet 6.3 (4.6-8.6), buttocks 3.1 (2.2-4.5), and perineum 2.5 (1.7-3.7), subdural hematoma (OR 8.2, 6.1-11), hypoxic ischemic injury (OR 4.2, CI 0.6-2.7), and retinal hemorrhages (OR 14.7, CI 6.4 to 33.6) among others. Of note, hollow viscus injuries, particularly duodenal injuries in children < 4 years were indicative of NAT. While there is substantial research on factors associated with NAT, future work is needed to standardize the definition of NAT for investigation and practice, such that evidence-based guidelines can be created to inform trauma providers when a comprehensive NAT evaluation is indicated.

Clinical Predictors of Shigella and Campylobacter Infection in Children in the United States

Abstract Background Infectious gastroenteritis is a major cause of morbidity and mortality among children worldwide. While most episodes are self-limiting, for select pathogens such as Shigella and Campylobacter, etiological diagnosis may allow effective antimicrobial therapy and aid public health interventions. Unfortunately, clinical predictors of such pathogens are not well established and are based on small studies using bacterial culture for identification. Methods We used prospectively collected data from a multi-center study of pediatric gastroenteritis employing multi-pathogen molecular diagnostics to determine clinical predictors associated with 1) Shigella and 2) Shigella or Campylobacter infection. We used machine learning algorithms for clinical predictor identification, then performed logistic regression on features extracted plus pre-selected variables of interest. Results Of 993 children enrolled with acute diarrhea, we detected Shigella spp. in 56 (5.6%) and Campylobacter spp. in 24 (2.4%). Compared with children who had neither pathogen detected (of whom, >70% had ≥1 potential pathogen identified), bloody diarrhea (odds ratio 4.0), headache (OR 2.2), fever (OR 7.1), summer (OR 3.3), and sick contact with GI illness (OR 2.2), were positively associated with Shigella, and out-of-state travel (OR 0.3) and vomiting and/or nausea (OR 0.4) were negatively associated (Table). For Shigella or Campylobacter, predictors were similar but season was no longer significantly associated with infection. Conclusion These results can create prediction models and assist clinicians with identifying patients who would benefit from diagnostic testing and earlier antibiotic treatment. This may curtail unnecessary antibiotic use, and help to direct and target appropriate use of stool diagnostics. Disclosures A. Leber, BioFIre Diagnostics: Research Contractor and Scientific Advisor, Research support, Speaker honorarium and Travel expenses J. Daly, Biofire: Grant Investigator, Grant recipient R. Selvarangan, BioFire Diagnostics: Board Member and Investigator, Consulting fee and Research grant Luminex Diagnostics: Investigator, Research grant J. Dien Bard, BioFire: Consultant and Investigator, Research grant and Speaker honorarium K. Holmberg, BioFire Diagnostics: Employee, Salary K. Bourzac, BioFire Diagnostics: Employee, Salary K. C. Chapin, BioFire Diagnstics: Investigator, Research support A. Pavia, BioFire Diagnostics: Grant Investigator, Research grant

Sexual Assault: What Every Emergency Provider Needs to Know.

Approximately one in three women and one in thirty men will be sexually assaulted at some point in their lives. While fewer than half of the survivors of sexual assault seek medical care, the majority of those who do are evaluated in emergency departments. Providing comprehensive care of sexually assaulted patients requires knowledge of the complex medical, psychological, and legal needs of this unique and vulnerable population. Unfortunately, formal education regarding best practices in providing care for victims of sexual assault is lacking in emergency medicine (EM) training. In this 30-minute video, we will review the epidemiology of sexual assault; present the current state of sexual assault education in EM; highlight interventions essential to the care of sexually assaulted patients; and provide concrete strategies to systemically improve care for these patients. Additionally, learners will become familiar with the practical steps of performing a sexual assault evidence collection kit; understand the indications for post-exposure testing and prophylaxis; and review appropriate referral for follow-up for sexually assaulted patients. LINK TO VIDEO: https://vimeo.com/162540864 PASSWORD: perls This article is protected by copyright. All rights reserved.This article is protected by copyright. All rights reserved. Language: en