Faculty Bibliography

OBJECTIVES: Describe the epidemiology of pediatric psychiatric-related visits to emergency departments participating in the Pediatric Emergency Care Applied Research Network. METHODS: Retrospective analysis of emergency department presentations for psychiatric-related visits (International Classification of Diseases, Ninth Revision, codes 290.0-314.90) for years 2003 to 2005 at 24 participating Pediatric Emergency Care Applied Research Network hospitals. All patients who had psychiatric-related emergency department visits aged 19 years or younger were eligible. Age, sex, race, ethnicity, insurance status, mode of arrival, length of stay, and disposition were described for psychiatric-related visits and compared with non-psychiatric-related visits. RESULTS: Pediatric psychiatric-related visits accounted for 3.3% of all participating emergency department visits (84,973/2,580,299). Patients with psychiatric-related visits were older (mean +/- SD age, 12.7 +/- 3.9 years vs. 5.9 +/- 5.6 years, P < 0.001), had a higher rate ambulance arrival (19.4% vs 8.2%, P < 0.0001), had a longer median length of stay (3.2 vs 2.1 hours, P < 0.0001), and had a higher rate of admission (30.5% vs 11.2%, P < 0.0001) when compared with non-psychiatric-related patient presentations. Older age, female sex, white race, ambulance arrival, and governmental insurance were factors independently associated with admission or transfer from the emergency department for psychiatric-related visits in multivariate regression analyses. CONCLUSIONS: Pediatric psychiatric-related visits require more prehospital and emergency department resources and have higher admission/transfer rates than non-psychiatric-related visits within a large national pediatric emergency network

BACKGROUND: CT imaging of head-injured children has risks of radiation-induced malignancy. Our aim was to identify children at very low risk of clinically-important traumatic brain injuries (ciTBI) for whom CT might be unnecessary. METHODS: We enrolled patients younger than 18 years presenting within 24 h of head trauma with Glasgow Coma Scale scores of 14-15 in 25 North American emergency departments. We derived and validated age-specific prediction rules for ciTBI (death from traumatic brain injury, neurosurgery, intubation >24 h, or hospital admission >or=2 nights). FINDINGS: We enrolled and analysed 42 412 children (derivation and validation populations: 8502 and 2216 younger than 2 years, and 25 283 and 6411 aged 2 years and older). We obtained CT scans on 14 969 (35.3%); ciTBIs occurred in 376 (0.9%), and 60 (0.1%) underwent neurosurgery. In the validation population, the prediction rule for children younger than 2 years (normal mental status, no scalp haematoma except frontal, no loss of consciousness or loss of consciousness for less than 5 s, non-severe injury mechanism, no palpable skull fracture, and acting normally according to the parents) had a negative predictive value for ciTBI of 1176/1176 (100.0%, 95% CI 99.7-100 0) and sensitivity of 25/25 (100%, 86.3-100.0). 167 (24.1%) of 694 CT-imaged patients younger than 2 years were in this low-risk group. The prediction rule for children aged 2 years and older (normal mental status, no loss of consciousness, no vomiting, non-severe injury mechanism, no signs of basilar skull fracture, and no severe headache) had a negative predictive value of 3798/3800 (99.95%, 99.81-99.99) and sensitivity of 61/63 (96.8%, 89.0-99.6). 446 (20.1%) of 2223 CT-imaged patients aged 2 years and older were in this low-risk group. Neither rule missed neurosurgery in validation populations. INTERPRETATION: These validated prediction rules identified children at very low risk of ciTBIs for whom CT can routinely be obviated. FUNDING: The Emergency Medical Services for Children Programme of the Maternal and Child Health Bureau, and the Maternal and Child Health Bureau Research Programme, Health Resources and Services Administration, US Department of Health and Human Services

Objectives: The objectives were to determine whether pretreatment with needleless jet-delivered lidocaine decreases self-reported pain in children undergoing needle insertion in the emergency department (ED) and to explore whether pretreatment with a jet device decreases self-reported pain in children undergoing needle insertion in the ED. Methods: This study examined needle insertion pain in children 5-18 years of age. In the first phase of this study, children received either pretreatment with jet-delivered lidocaine (0.2 mL of buffered 1% lidocaine; n = 75) or pretreatment with jet-delivered placebo (0.2 mL of preservative-free normal saline; n = 75) 60 seconds before undergoing needle insertion. This phase of the study had a randomized, double-blind, placebo-controlled design. In the second phase, an unblinded, nonconcurrent, nonintervention control group (n = 47) was examined to describe any effect of using the jet device. Patients reported pain upon administration of the jet device and at needle insertion using a 100-mm color analog scale (CAS). Patients also reported their satisfaction with this device. The physicians and nurses performing needle insertions were asked to rate their ability to visualize the vein and their satisfaction with the device. Results: The mean (+/-standard deviation [SD]) needle insertion pain score for jet lidocaine, 28 (+/-7) mm, was similar to the mean needle insertion pain score for jet placebo, 34 (+/-7) mm. The mean needle insertion pain score for both the jet lidocaine and the jet placebo groups were lower than the needle insertion pain scores for the no device group, 52 (+/-8) mm. The majority of patients receiving the jet device reported that they would request this device for future needle insertions. Providers' ratings of their ability to visualize veins and the patient cooperation were similar in all three groups. Conclusions: Jet-delivered lidocaine is no more effective than jet-delivered placebo in providing local anesthesia for needle insertion. Jet lidocaine and jet placebo may provide superior analgesia compared to no local anesthetic pretreatment

OBJECTIVE: To describe the patterns of referral and use of resources for patients with psychiatric-related visits presenting to pediatric emergency departments (EDs) in a pediatric research network. METHODS: We conducted a retrospective chart review of a random sample of patients (approximately 10 charts per month per site) who presented with psychiatric-related visits in 2002 to 4 pediatric EDs in the Pediatric Emergency Care Applied Research Network. Emergency department resource use variables evaluated included the use of consultation services, restraints, and laboratory tests as well as ED length of stay. RESULTS: We reviewed 462 patient visits with a psychiatric-related ED diagnosis. Mean (SD) age was 12.8 (3.7) years, 52% were male, and 49% were African American. The most common chief complaints were suicidality (47%), aggression/agitation (42%), and anxiety/depression (27%), alone or in combination. Ninety percent of patients (range across sites, 83%-94%) had a mental health consult in the ED, 5% were restrained (range, 3%-9%), and 35% had a laboratory test performed (range, 15%-63%). Mean (SD) ED length of stay was 5.1 (5.4) hours, and 52% were admitted (93% to a psychiatric bed, including transfers to separate psychiatric facilities). CONCLUSIONS: Children with psychiatric-related visits seem to require substantial ED resources. Interventions are needed to reduce the burden on the ED by increasing the linkage to mental health services, particularly for suicidal youths

In recent years, attention has been given to disaster preparedness for first responders and first receivers (hospitals). One such focus involves the decontamination of individuals who have fallen victim to a chemical agent from an attack or an accident involving hazardous materials. Children often are overlooked in disaster planning. Children are vulnerable and have specific medical and psychological requirements. There is a need to develop specific protocols to address pediatric patients who require decontamination at the entrance of hospital emergency departments. Currently, there are no published resources that meet this need. An expert panel convened by the New York City Department of Health and Mental Hygiene developed policies and procedures for the decontamination of pediatric patients. The panel was comprised of experts from a variety of medical and psychosocial areas. Using an iterative process, the panel created guidelines that were approved by the stakeholders and are presented in this paper. These guidelines must be utilized, studied, and modified to increase the likelihood that they will work during an emergency situation

A prospective observational study of 4,653 consecutive cases of out-of-hospital cardiac arrest (OOHCA) occurring in New York City from April 1, 2002, to March 31, 2003, was used to assess racial/ethnic differences in the incidence of OOHCA and 30-day survival after hospital discharge among OOHCA patients. The age-adjusted incidence of OOHCA per 10,000 adults was higher among Blacks than among persons in other racial/ethnic groups, and age-adjusted survival from OOHCA was higher among Whites compared with other groups. In analyses restricted to 3,891 patients for whom complete data on all variables were available, the age-adjusted relative odds of survival from OOHCA among Blacks were 0.4 (95% confidence interval: 0.2, 0.7) as compared with Whites. A full multivariable model accounting for demographic factors, prior functional status, initial cardiac rhythm, and characteristics of the OOHCA event explained approximately 41 percent of the lower age-adjusted survival among Blacks. The lower prevalence of ventricular fibrillation as the initial cardiac rhythm among Blacks relative to Whites was the primary contributor. A combination of factors probably accounts for racial/ethnic disparities in OOHCA survival. Previously hypothesized factors such as delays in emergency medical service response or differences in the likelihood of receipt of cardiopulmonary resuscitation did not appear to be substantial contributors to these racial/ethnic disparities

OBJECTIVE: The goal was to assess the knowledge and confidence in recognition, management, documentation, and reporting of child maltreatment among a representative sample of emergency medical services personnel in the United States. METHODS: A questionnaire was developed and pilot-tested, with the input of experts in emergency medical services and child maltreatment, to assess knowledge, attitudes, confidence, and training needs regarding assessment and treatment of child maltreatment. The questionnaire was distributed nationally to a random sample of prehospital providers by using a previously validated sampling plan. RESULTS: Of 2863 surveys sent to prehospital providers, 1237 (43%) were returned. Most prehospital providers reported receiving < or = 1 hour of continuing medical education regarding child maltreatment. Most (78%) asked for additional educational opportunities, with only 3% stating that they required no additional training. Participants lacked knowledge regarding the developmental abilities of children, management of families in which child maltreatment is suspected, key elements of the history that should be noted, and the degree of suspicion necessary for reporting. CONCLUSIONS: Prehospital providers expressed confidence in their abilities to recognize and to manage cases of child abuse and neglect; however, significant deficiencies were reported in several critical knowledge areas, including identification of child maltreatment, interviewing techniques, and appropriate documentation

Most published recommendations for treatment of pediatric nerve agent poisoning are based on standard resuscitation doses for these agents. However, certain medical and operational concerns suggest that an alternative approach may be warranted for treatment of children by emergency medical personnel after mass chemical events. (1) There is evidence both that suprapharmacological doses may be warranted and that side effects from antidote overdosage can be tolerated. (2) There is concern that many emergency medical personnel will have difficulty determining both the age of the child and the severity of the symptoms. Therefore, the Regional Emergency Medical Advisory Committee of New York City and the Fire Department, City of New York, Bureau of Emergency Medical Services, in collaboration with the Center for Pediatric Emergency Medicine of the New York University School of Medicine and the Bellevue Hospital Center, have developed a pediatric nerve agent antidote dosing schedule that addresses these considerations. These doses are comparable to those being administered to adults with severe symptoms and within limits deemed tolerable after inadvertent nerve agent overdose in children. We conclude that the above approach is likely a safe and effective alternative to weight-based dosing of children, which will be nearly impossible to attain under field conditions