Faculty Bibliography

Study Objectives: To evaluate clinical decisionmaking by emergency physicians using IVC US in children undergoing ED evaluation of dehydration from GI losses. Dehydration from gastroenteritis is a leading cause of death in children <5 years worldwide. US assessment of the IVC may correlate with severity of dehydration and assist in clinical decision making. Methods: We conducted a prospective cohort study of US imaging of the IVC in pediatric patients with suspected dehydration from vomiting and/or diarrhea. The IVC was imaged in the sagittal plane at the junction of the right atrium and along the length of the IVC extending into the liver, assessing for 100% collapse of the walls of the IVC with tidal breathing. Patients < 21 yrs. presenting with vomiting requiring ondansetron or diarrhea with concern for dehydration were eligible for study inclusion. Patients enrolled from 10/2015-12/2016. Clinical dehydration scores, pre-test (before IVC US) and post-test (after IVC US) probabilities of dehydration requiring IV fluids were recorded by 5 treating sonologists that enrolled patients into the study. Primary outcomes assessed included: IV vs PO fluid rehydration, ED length of stay (LOS) and disposition (admission or discharge). Results: One hundred twelve patients were enrolled, median age was 5 years (S.D +/-6), and 49.1% were female. By clinical dehydration score, 61.6% (n/N=69/112; 95% CI: 51.9-70.6%), 36.6% (n/N=41/112; 95% CI: 27.7-46.2%), and 0.01% (n/N=2/112; 95% CI: 0.0-0.06%) were minimally, moderately and severely dehydrated respectively. The majority of patients received oral rehydration 79.4% (n/N 89/112; 95 CI: 70.8-86.5%) and 20.5% (n/N=23/112; 95% CI: 13.5-29.2%) received IV fluid rehydration. Only 4.4% (n/N=5/112; 95% CI: 0.1-8.3%) were admitted and no discharged patient returned to the ED for failure to rehydrate. The distribution of pre-test to post-test probabilities in children with suspected dehydration requiring IV fluids is presented in matrix Figure 1. Overall, IVC US altered pre-test probabilities for requiring IV fluid rehydration by decreasing in 51.8% (n/N=58/112; 95% CI: 42.1-61.3%), increasing in 25% (n/N=26/112; 95% CI: 17.3-34.1), and left unchanged in 23.2% (n/N=28/112; 95% CI: 15.8-32.1%). IVC US was attributed to changing management in 15.2% (n/N=17/112; 95% CI: 9.1-23.2%) patients; from PO to IV fluid rehydration in 6.3% (n/N=7/112) children and from IV to PO rehydration in 8.9% (n/N=10/112) patients. Conclusions: US changes pre-test to post-test probabilities for requiring IV fluid rehydration in the majority of children with suspected dehydration, but in a population of mildly to moderately dehydrated children actual management change with respect to IV vs PO rehydration was infrequent. [Image Presented]

Burns in patients aged < 14 years are consistently among the top causes of injury-induced mortality in pediatric patients. Pediatric burn victims with large body surface area involvement have a multisystem physiologic response that differs from that of adult patients. The spectrum of management is vast and relies heavily on both the classification of the burn and the anatomy involved. Immediate goals for emergency clinicians include resuscitation and stabilization, fluid management, and pain control. Additional goals include decreasing the risk of infection along with improving healing and cosmetic outcomes. Discharge care and appropriate follow-up instructions need to be carefully constructed in order to avoid long-standing complications. This article reviews methods for accurate classification and management of the full range of burns seen in pediatric patients.

BACKGROUND: A validated tool has long been sought to provide clinicians with a uniform and accurate method to assess hydration status in the pediatric emergency medicine population. Outpatient clinicians use CDC height- and weight-based curves for the assessment of physical development. In hospital, daily weights provide objective data; however, these are usually not available at presentation.One of the most promising techniques for the rapid assessment of volume is ultrasound (US) to obtain an indexed inferior vena cava diameter (IVCDi); as previously described. Prior studies have focused on IVCDi in dehydrated patients and have shown that it provides accurate estimates of right atrial pressure and volume status. The objective of this study is to derive an IVC growth curve in healthy pediatric patients. METHODS: Prospective cohort design enrolled healthy children between the ages of 4 weeks and 20 years. Patients presenting with fever, illnesses, or diagnoses known to affect the volume will be excluded. All eligible patients under 21, who have provided self or parental written consent, will undergo a brief ultrasound to obtain transverse and long images of both the IVC and the aorta; all scans will be digitally saved. Image quality will be subjectively rated as poor, fair, or good based on wall clarity. Poor quality images will be recorded but may be omitted from our analysis. Five clinicians completed a 1-h introduction to IVC-US and ten supervised scans prior to enrollment. Still images will be measured in order to determine IVCDi in both transverse and longitudinal planes. To assess inter-rater reliability, in 10% of cases, two clinicians will complete scans. All study scans will be over-read by a fellowship-trained sonologist.IVCDi will be plotted independently as functions of age, gender, BMI, and aortic diameter. Within each group, means with means or medians with 95% CIs will be calculated. Following uni- and bivariate analyses and assessment for colinearity, a variety of parametric and nonparametric regression procedures will be conducted. The smoothed curves will be approximated using a modified LMS estimation procedure. RESULTS: Data for the initial curve derivation includes 25 patients ranging from 13 months to 20 years (mean 102 months or 8.5 years). Sixty-five percent of patients were enrolled from the ED, while 35% were enrolled from well-child clinic visits. When evaluating the size of IVC as a function of time linear growth, increasing size was found to proportionately increase with age of patient in months. CONCLUSIONS: Data suggest a linear correlation between IVC size and age. Such data, when plotted as a new growth curve, may allow clinicians to plot a patient's sonographic measurements in order to assess hydration health.

Acute gastroenteritis accounts for 1-2 million annual pediatric emergency department visits in the US. The current literature supports the use of antiemetics, such as ondansetron, in the emergency department, reporting improved oral rehydration, cessation of vomiting, and reduction in the need for intravenous rehydration. However, there remains concern that using these agents may "mask alternative diagnoses" and negatively impact patient care. We present a case series of 29 patients who received a pediatric emergency department discharge action plan which allowed for a dose of ondansetron to be dispensed by the clinician at the time of discharge. Patients were instructed to administer the ondansetron at home for treatment of ongoing nausea and vomiting any time after 6 hours from the time of emergency department discharge. These patients were followed up at 3-5 days following discharge to assess for outcomes. Implications of this discharge action plan and future directions are discussed.

OBJECTIVES: We examined the use of point-of-care (POC) testing of cardiac biomarkers against standard core laboratory testing to determine the time-savings and estimate a cost-benefit ratio at our institution. METHODS: We prospectively enrolled 151 patients presenting to the emergency department undergoing evaluation for acute coronary syndrome and conducted both central laboratory troponin T (TnT) testing at baseline and 6 hours as well as POC assays of creatine kinase MB, troponin I (TnI), and myoglobin at baseline and 2 hours. Sensitivity/specificity was calculated to measure the ability of the POC-accelerated pathway to identify enzyme elevations at rates parallel to our core laboratory. The time-savings were calculated as the difference between the median of the current protocol and the accelerated POC pathway. RESULTS: Troponin T tests were elevated in 12 patients, which were all detected by the accelerated pathway yielding a relative sensitivity of 100%. Time-saving between the accelerated pathway and core laboratory showed a saving of 390 minutes (6.5 hours). The accelerated POC pathway would have benefited 60% (95% confidence interval [CI], 52%-68%) of our patients with an estimated cost of $7.40 (95% CI, $6.40-$8.70) per direct patient care hour saved. CONCLUSION: Our data suggest that the use of an accelerated cardiac POC pathway could have dramatically impacted the care provided to a large percentage of our patients at a minimal cost per direct patient care hour saved.