Faculty Bibliography

Currently, there is a limited evidence base in prehospital care, especially so in pediatric prehospital care. This is, in part, due to the many obstacles in conducting clinical trials in the prehospital setting requiring added resources and funding to accomplish. The Pediatric Emergency Care Applied Research Network and other organizations have only recently started to encourage the formation of systems to support prehospital research including practical state and national data registries

STUDY OBJECTIVE: We determine whether intra-abdominal injury is rarely diagnosed after a normal abdominal computed tomography (CT) scan result in a large, generalizable sample of children evaluated in the emergency department (ED) after blunt torso trauma. METHODS: This was a planned analysis of data collected during a prospective study of children evaluated in one of 20 EDs in the Pediatric Emergency Care Applied Research Network. The study sample consisted of patients with normal results for abdominal CT scans performed in the ED. The principal outcome measure was the negative predictive value of CT for any intra-abdominal injury and those undergoing acute intervention. RESULTS: Of 12,044 enrolled children, 5,380 (45%) underwent CT scanning in the ED; for 3,819 of these scan the results were normal. Abdominal CT had a sensitivity of 97.8% (717/733; 95% confidence interval [CI] 96.5% to 98.7%) and specificity of 81.8% (3,803/4,647; 95% CI 80.7% to 82.9%) for any intra-abdominal injury. Sixteen (0.4%; 95% CI 0.2% to 0.7%) of the 3,819 patients with normal CT scan results later received a diagnosis of an intra-abdominal injury, and 6 of these underwent acute intervention for an intra-abdominal injury (0.2% of total sample; 95% CI 0.06% to 0.3%). The negative predictive value of CT for any intra-abdominal injury was 99.6% (3,803/3,819; 95% CI 99.3% to 99.8%); and for injury undergoing acute intervention, 99.8% (3,813/3,819; 95% CI 99.7% to 99.9%). CONCLUSION: In a multicenter study of children evaluated in EDs after blunt torso trauma, intra-abdominal injuries were rarely diagnosed after a normal abdominal CT scan result, suggesting that safe discharge is possible for the children when there are no other reasons for admission.

STUDY OBJECTIVE: We derive a prediction rule to identify children at very low risk for intra-abdominal injuries undergoing acute intervention and for whom computed tomography (CT) could be obviated. METHODS: We prospectively enrolled children with blunt torso trauma in 20 emergency departments. We used binary recursive partitioning to create a prediction rule to identify children at very low risk of intra-abdominal injuries undergoing acute intervention (therapeutic laparotomy, angiographic embolization, blood transfusion for abdominal hemorrhage, or intravenous fluid for >/=2 nights for pancreatic/gastrointestinal injuries). We considered only historical and physical examination variables with acceptable interrater reliability. RESULTS: We enrolled 12,044 children with a median age of 11.1 years (interquartile range 5.8, 15.1 years). Of the 761 (6.3%) children with intra-abdominal injuries, 203 (26.7%) received acute interventions. The prediction rule consisted of (in descending order of importance) no evidence of abdominal wall trauma or seat belt sign, Glasgow Coma Scale score greater than 13, no abdominal tenderness, no evidence of thoracic wall trauma, no complaints of abdominal pain, no decreased breath sounds, and no vomiting. The rule had a negative predictive value of 5,028 of 5,034 (99.9%; 95% confidence interval [CI] 99.7% to 100%), sensitivity of 197 of 203 (97%; 95% CI 94% to 99%), specificity of 5,028 of 11,841 (42.5%; 95% CI 41.6% to 43.4%), and negative likelihood ratio of 0.07 (95% CI 0.03 to 0.15). CONCLUSION: A prediction rule consisting of 7 patient history and physical examination findings, and without laboratory or ultrasonographic information, identifies children with blunt torso trauma who are at very low risk for intra-abdominal injury undergoing acute intervention. These findings require external validation before implementation.

STUDY OBJECTIVE: We compare the prevalence of clinically important traumatic brain injuries and the use of cranial computed tomography (CT) in children with minor blunt head trauma with and without ventricular shunts. METHODS: We performed a secondary analysis of a prospective observational cohort study of children with blunt head trauma presenting to a participating Pediatric Emergency Care Applied Research Network emergency department. For children with Glasgow Coma Scale (GCS) scores greater than or equal to 14, we compared the rates of clinically important traumatic brain injuries (defined as a traumatic brain injury resulting in death, neurosurgical intervention, intubation for more than 24 hours, or hospital admission for at least 2 nights for management of traumatic brain injury in association with positive CT scan) and use of cranial CT for children with and without ventricular shunts. RESULTS: Of the 39,732 children with blunt head trauma and GCS scores greater than or equal to 14, we identified 98 (0.2%) children with ventricular shunts. Children with ventricular shunts had more frequent CT use: (45/98 [46%] with shunts versus 13,858/39,634 [35%] without; difference 11%; 95% confidence interval 1% to 21%) but a similar rate of clinically important traumatic brain injuries (1/98 [1%] with shunts versus 346/39,619 [0.9%] without; difference 0.1%; 95% confidence interval -0.3% to 5%). The one child with a ventricular shunt who had a clinically important traumatic brain injury had a known chronic subdural hematoma that was larger after the head trauma compared with previous CT; the child underwent hematoma evacuation. CONCLUSION: Children with ventricular shunts had higher CT use with similar rates of clinically important traumatic brain injuries after minor blunt head trauma compared with children without ventricular shunts.

OBJECTIVE: To determine the accuracy of point-of-care ultrasonography for the diagnosis of pneumonia in children and young adults by a group of clinicians. DESIGN: Prospective observational cohort study. SETTING: Two urban emergency departments. PARTICIPANTS: Patients from birth to age 21 years undergoing chest radiography for suspected community-acquired pneumonia. INTERVENTION: After documenting clinical examination findings, clinicians with 1 hour of focused training used ultrasonography to diagnose pneumonia in children and young adults. MAIN OUTCOMES MEASURES: Test performance characteristics for the ability of ultrasonography to diagnose pneumonia were determined using chest radiography as a reference standard. Subgroup analysis was performed in patients having lung consolidation exceeding 1 cm with sonographic air bronchograms detected on ultrasonography; specificity and positive likelihood ratio (LR) were calculated to account for lung consolidation of 1 cm or less with sonographic air bronchograms undetectable by chest radiography. RESULTS: Two hundred patients were studied (median age, 3 years; interquartile range, 1-8 years); 56.0% were male, and the prevalence of pneumonia by chest radiography was 18.0%. Ultrasonography had an overall sensitivity of 86% (95% CI, 71%-94%), specificity of 89% (95% CI, 83%-93%), positive LR of 7.8 (95% CI, 5.0-12.4), and negative LR of 0.2 (95% CI, 0.1-0.4) for diagnosing pneumonia by visualizing lung consolidation with sonographic air bronchograms. In subgroup analysis of 187 patients having lung consolidation exceeding 1 cm, ultrasonography had a sensitivity of 86% (95% CI, 71%-94%), specificity of 97% (95% CI, 93%-99%), positive LR of 28.2 (95% CI, 11.8-67.6) and negative LR of 0.1 (95% CI, 0.1-0.3) for diagnosing pneumonia. CONCLUSION: Clinicians are able to diagnose pneumonia in children and young adults using point-of-care ultrasonography, with high specificity.

OBJECTIVES: The objective of this study was to describe the demographics of out-of-hospital cardiac arrests (OOHCAs) in children younger than 18 years and characteristics associated with survival among these children in New York City (NYC). METHODS: A prospective observational cohort of all children younger than 18 years with OOHCA in NYC between April 1, 2002, and March 31, 2003. Data were collected from prehospital providers by trained paramedics utilizing a previously validated telephone interview process. Data included Pediatric Utstein core measures and critical prehospital time intervals. Analyses utilized descriptive statistics and bivariate association with survival. RESULTS: Resuscitation was attempted on 147 pediatric OOHCA patients in NYC during the study period; outcome data were collected on these patients. The median age was 2 years; most (58%) were male. The majority of arrests occurred at home (69%). Lay bystanders witnessed 33% of all OOHCA; 68% of witnesses were family members. Bystander cardiopulmonary resuscitation (CPR) was performed on 30% of children. Median emergency medical services response time was 3.6 minutes (range, 0.4-14.4 minutes). Initial rhythm was as follows: ventricular fibrillation, 2%; asystole, 50%; pulseless electrical activity, 9.5%; other rhythms, 11.6%; no rhythm recorded, 26%. Survival was 4% to hospital discharge and was present only among witnessed arrests (6/58 witnessed vs 0/70 unwitnessed, P < 0.05). CONCLUSIONS: Pediatric OOHCA survival rate is low. Witnessed arrest was the most important determinant of survival. Ventricular fibrillation was an uncommon rhythm measured by emergency medical services. The majority of arrests occurred at home. The rate of bystander CPR was low. Strategies to increase the rate of bystander CPR for children, especially by family members, are needed.

OBJECTIVE: The objective of this study was to describe the demographics, epidemiology, and characteristics associated with survival of children younger than 18 years who had an out-of-hospital respiratory arrest (OOHRA) during a 1-year period in a large urban area. METHODS: A prospective observational cohort of consecutive children younger than 18 years with OOHRA cared for by the New York City 911 emergency medical services (EMS) system from April 12, 2002, to March 31, 2003. Following resuscitative efforts, data were collected from prehospital providers by trained paramedics using a previously validated telephone interview process. Data included Pediatric Utstein core measures and critical prehospital time intervals. Analyses used descriptive statistics and bivariate association with survival. RESULTS: Resuscitation was attempted on 109 OOHRAs during the study period. The median age was 7 years, 52% were male. Lay bystanders witnessed 56%. Most occurred at home (77%). Witnesses were family members in 59%. Bystander cardiopulmonary resuscitation (CPR) was performed in 31% of all respiratory arrests (RAs). A chronic medical condition existed in 28%. Median EMS response time was 4.4 minutes (range, 0-12 min). Overall survival was 79% to hospital discharge. Time interval to EMS arrival, witnessed arrest, bystander CPR, and ventilation method were not associated with survival. CONCLUSIONS: Most OOHRAs occurred at home, and bystander CPR occurred infrequently. The majority of children in OOHRA survived. Strategies to increase the rate of bystander CPR, especially by family members, are needed. Out-of-hospital RAs are a large proportion of all arrests in children. Future studies of pediatric arrest should include RA as well as cardiac arrest.

OBJECTIVE: Treating or referring patients who are found to be anemic during pediatric emergency department (ED) encounters should lead to improved health in children and young adults. Before establishing guidelines how to approach the anemic in the pediatric ED, it is essential to determine the prevalence of anemia in the ED and our response to the presence of anemia. METHODS: We performed a retrospective cross-sectional study on hemoglobin levels from patients 1 to 23 years evaluated in an inner-city public hospital pediatric ED during a 12-month period. The primary outcome measure was the prevalence of prior unknown or "occult" anemia, stratified by age, sex, and insurance status. The secondary outcome was the proportion of patients with "occult" anemia who had their condition diagnosed during their ED encounter. Descriptive data analysis was performed. RESULTS: Our study population consisted of 2131 patients who had a complete blood count drawn in the ED. Prevalence of "occult" anemia was 13.9% (95% confidence interval [CI], 12.5%-15.4%). Proportions among the subpopulations were 14.8% (95% CI, 10.0%-19.5%) in preschool children, 16.3% (95% CI, 14.2%-18.3%) in females, 18.5% (95% CI, 15.4%-21.7%) in the uninsured, and 20.7% (95% CI, 16.5%-24.9%) in females of childbearing age without insurance. Only 24 patients (8%) with "occult" anemia had the condition identified on discharge. CONCLUSIONS: Anemia has a high prevalence in this pediatric ED population, especially among females of childbearing age and the uninsured. Pediatric emergency medicine physicians are missing on an opportunity to address a common health problem that is easily corrected with appropriate therapy and outpatient follow-up.

Purpose: Children are frequently the victims of both natural disasters and specific acts of terror; however there is a lack of organized pediatric emergency preparedness planning for mass casualty incidents (MCI). To address these gaps, a large urban Department of Health (DOH) established a federal grant funded Pediatric Disaster Coalition (PDC), which established guidelines for creating Pediatric Critical Care (PCC) surge plans and is currently assisting hospitals in implementing them. This city with a population of over 8 million people (approximately 25% of whom are < 18 years of age) has 25 hospitals with PCC services with a total of 235 PICU beds. Recently, there was a failed attempt to detonate a car bomb on a Saturday evening in the center of this large city. Had the bomb exploded, given the location and time of day, it is probable that many of the critically injured victims would have been children. Methods: One week following the event we conducted a telephone survey of PCC leadership at 9 hospitals with PCC capability in the immediate area to determine the number of vacant PCC beds at the time of the event, before activation of any surge plans. Results: At the time the car bomb was discovered, these 9 hospitals with a total of 141 PCC beds (60% of cities total 235 beds) had 29 vacant pediatric critical care beds. Had the event resulted in many pediatric casualties, the existing PCC vacant beds at these hospitals would not have been sufficient. Activating newly developed PDC surge plans at 5 of these hospitals would have added 92 surge beds to the 29 available PCC beds for a total of 121. Conclusion: In order to provide PCC to a large number of victims following an MCI it is crucial that hospitals prepare PCC surge plans. Once all 25 hospitals in this city complete surge plans it is estimated there should be an ability to add over 200 PCC surge beds, potentially increasing PCC surge capacity by 85%. Plans are currently being developed to drill and evaluate these PDC surge plans