Atropine does not prevent hypoxemia and bradycardia in tracheal intubation in the pediatric emergency department: observational study / O uso da atropina não previne hipoxemia e bradicardia na intubação traqueal no departamento de emergência pediátrica: estudo observacional

ABSTRACT Objective: The benefit of atropine in pediatric tracheal intubation is not well established. The objective of this study was to evaluate the effect of atropine on the incidence of hypoxemia and bradycardia during tracheal intubations in the pediatric emergency department. Methods: This is a single-center observational study in a tertiary pediatric emergency department. Data were collected on all tracheal intubations in patients from 31 days to incomplete 20 years old, performed between January 2016 and September 2020. Procedures were divided into two groups according to the use or not of atropine as a premedication during intubation. Records with missing data, patients with cardiorespiratory arrest, cyanotic congenital heart diseases, and those with chronic lung diseases with baseline hypoxemia were excluded. The primary outcome was hypoxemia (peripheral oxygen saturation ≤88%), while the secondary outcomes were bradycardia (decrease in heart rate >20% between the maximum and minimum values) and critical bradycardia (heart rate <60 bpm) during intubation procedure. Results: A total of 151 tracheal intubations were identified during the study period, of which 126 were eligible. Of those, 77% had complex, chronic underlying diseases. Atropine was administered to 43 (34.1%) patients and was associated with greater odds of hypoxemia in univariable analysis (OR: 2.62; 95%CI 1.15-6.16; p=0.027) but not in multivariable analysis (OR: 2.07; 95%CI 0.42-10.32; p=0.37). Critical bradycardia occurred in only three patients, being two in the atropine group (p=0.26). Bradycardia was analyzed in only 42 procedures. Atropine use was associated with higher odds of bradycardia in multivariable analysis (OR: 11.00; 95%CI 1.3-92.8; p=0.028). Conclusions: Atropine as a premedication in tracheal intubation did not prevent the occurrence of hypoxemia or bradycardia during intubation procedures in pediatric emergency.

RESUMO Objetivo: Avaliar o efeito da atropina na incidência de hipoxemia e bradicardia durante a intubação orotraqueal no departamento de emergência pediátrica. Métodos: Estudo observacional, realizado em departamento de emergência pediátrica terciário em que foram analisados os registros de intubações orotraqueais de pacientes com 31 dias a 20 anos incompletos, entre janeiro de 2016 e setembro de 2020. Os procedimentos foram divididos em dois grupos de acordo com o uso ou não da atropina como pré-medicação durante a intubação. Foram excluídos os procedimentos com falhas no preenchimento dos dados, pacientes com parada cardiorrespiratória, cardiopatias congênitas cianóticas, e aqueles com pneumopatias crônicas com hipoxemia basal. O desfecho primário foi hipoxemia (saturação periférica de oxigênio ≤88%), enquanto os desfechos secundários foram bradicardia (queda >20% entre a frequência cardíaca máxima e mínima) e bradicardia crítica (frequência cardíaca <60 bpm) durante o procedimento de intubação Resultados: Foram identificados 151 procedimentos de intubação orotraqueal, sendo 126 elegíveis para o estudo. Desses, 77% tinham doenças subjacentes complexas e crônicas. A atropina foi administrada em 43 (34,1%) pacientes e foi associada a maiores chances de hipoxemia na análise univariada (OR: 2,62; IC95% 1,15-6,16; p=0,027), porém, não na análise multivariada (OR: 2,073; IC95% 0,416-10,32; p=0,373). A bradicardia crítica ocorreu em apenas três pacientes, sendo dois no grupo atropina (p=0,268). A bradicardia foi analisada em apenas 42 procedimentos. O uso de atropina foi associado a maior probabilidade de bradicardia (OR: 11,00; IC95% 1,3-92,8; p=0,028) na análise multivariável. Conclusões: Atropina como pré-medicação na intubação orotraqueal não evitou a ocorrência de hipoxemia ou bradicardia durante os procedimentos de intubação na emergência pediátrica.

How to incorporate telemedicine in medical residency: A Brazilian experience in pediatric emergency

ABSTRACT Introduction: The exponential growth of telehealth services during the COVID-19 pandemic led to the implementation of a telemedicine care service in a tertiary university pediatric hospital. It brought the need to develop a training aimed at remote care within the pediatric emergency rotation program. Objective: To describe the implementation of a telemedicine training for pediatric residents and present the preliminary results. Methods: Descriptive prospective study (pre and post), with 40 resident physicians of the first year of pediatrics. Reaction Assessments were applied before and after training, in addition to a resident physician perception questionnaire at the end of the training. Results: There was a significant difference in the resident's perception of experience and safety after initial training. Most rated the proposal as good or excellent, considered teaching telemedicine relevant and that this experience contributed to their learning on the subject. Conclusion: This study describes an innovative proposal for training in telemedicine. The preliminary results were encouraging, demonstrating the program's potential in training future pediatricians.

Pediatric emergency triage systems / Sistemas de triagem em emergência pediátrica

ABSTRACT Objective: The aim of this study was to perform a narrative review of the leading pediatric triage systems in emergency departments (EDs). Data source: Articles published between 1999 and 2019 were identified by searching the MEDLINE, EMBASE, and PubMed databases using the keywords "pediatric triage", "pediatric assessment tools", and "emergency department triage" with an emphasis on studies that evaluated the validation and reliability of triage systems. Data synthesis: A total of 105 articles on pediatric emergency triage systems in 12 countries were evaluated. Triage systems were divided into two groups: color-stratified triage systems and alert systems. The color-stratified triage systems included in this review were the Canadian Triage and Acuity Scale (CTAS), Manchester Triage System (MTS), Emergency Severity Index (ESI), and Australasian Triage Scale (ATS), and the alert systems included were the Paediatric Observation Priority Score (POPS), Pediatric Early Warning Score (PEWS), and Pediatric Approach Triangle (PAT). Evidence corroborates the validity and reliability of MTS, PaedCTAS, ESI version 4, PEWS, POPS, and PAT in pediatric emergency services. Conclusions: These are fundamental tools for risk classification of patients seeking treatment in EDs. Not all triage systems have been assessed for validity and reliability; nor are they well suited for all regions of the world. Employing triage systems in Brazil requires cultural adaptation and rigorous training of the local health staff, in addition to validation and reliability studies in our country, since the social and cultural context of this country differs from those where these tools were developed.

RESUMO Objetivo: Realizar uma revisão narrativa dos principais sistemas de triagem pediátrica nos serviços de emergência. Fontes de dados: Artigos publicados entre 1999 e 2019, obtidos por meio de busca nos bancos de dados Medical Literature Analysis and Retrieval System Online (Medline), Embase e PubMed usando as palavras-chave "pediatric triage", "pediatric assessment tools" e "emergency department triage", com ênfase em estudos que avaliaram a validação e a confiabilidade desses sistemas. Síntese dos dados: Foram avaliados 105 artigos sobre sistemas de triagem na emergência pediátrica de 12 países. Os sistemas de triagem foram divididos em dois grupos: estratificados por cores e de alerta. Os sistemas de triagem com estratificação por cores incluídos nesta revisão foram: Canadian Triage and Acuity Scale (CTAS), Manchester Triage System (MTS), Emergency Severity Index (ESI) e Australian Triage Scale (ATS). Os sistemas de alerta incluídos foram: Paediatric Observation Priority Score (POPS), Pediatric Early Warning Score (PEWS) e Pediatric Approach Triangle (PAT). Há evidências que corroboram a validade e a confiabilidade do MTS, PedCTAS, ESI v.4, PEWS, POPS e PAT em serviços de emergência de pediátricos. Conclusões: Os sistemas de triagem são ferramentas fundamentais para o atendimento de pacientes que procuram serviços de emergência. Nem todos os sistemas de triagem foram avaliados para validação e confiabilidade nem se aplicam a todas as regiões do mundo. Para a aplicação de sistemas de triagem no Brasil, devem ser feitos adaptação cultural e treinamento do estafe de saúde local, bem como estudos de validação e confiabilidade em nosso país, dado o seu contexto social e cultural diferente daquele dos países onde essas ferramentas foram desenvolvidas.

Analysis of death in children not submitted to cardiopulmonary resuscitation

Abstract Objective Describe the epidemiology of deaths in children not submitted to CPR, compare to a CPR group and evaluate patients' medical records of those not submitted to CPR. Methods Observational cross-sectional study assessing deaths between 2015 and 2018 in a pediatric tertiary hospital, divided into two groups: CPR and no- CPR. The source of data included the cardiorespiratory arrest register, based on Utstein style. Children's medical records in no-CPR group were researched by hand. Results 241 deaths were included, 162 in CPR group and 79 in the no-CPR group. Preexisting diseases were observed in 98.3% of patients and prior advanced intervention in 78%. Of the 241 deaths, 212 (88%) occurred in the PICU, being 138/162 (85.2%) in CPR group and 74/79 (93.7%) in no-CPR group (p= 0.018). Bradycardia as the initial rhythm was five times more frequent in the CPR group (OR 5.06, 95% CI 1.94-13,19). There was no statistically significant difference regarding age, gender, preexisting diseases, and period of the day of the occurrence of death. Medical records revealed factors related to the family decision-making process or the suitability of therapeutic effort. Discrepancies between the practice of CPR and medical records were identified in 9/79 (11,4%) records allocated to the no-CPR group. Conclusion Most deaths with CPR and with the no-CPR occurred in the PICU. Bradycardia as the initial rhythm was five times more frequent in the CPR group. Medical records reflected the complexity of the decision not to perform CPR. Discrepancies were identified between practice and medical records in the no-CPR group.

Fast, cheap and feasible: Implementation of pediatric telemedicine in a public hospital during the Covid-19 pandemic

Abstract Objective: In Brazil, telemedicine was allowed as an exception during the coronavirus disease (COVID-19) pandemic. Despite its recognized value and availability, telemedicine is not universally used, suggesting that some barriers prevent its adoption and acceptance within the community. This study aims to describe the implementation of a low-cost telemedicine service in a pediatric hospital in Brazil. Method: Retrospective descriptive study reporting the first three months (April to June 2020) of the experience of implementing a low-cost telemedicine emergency care program in a public tertiary hospital. The service was available to patients up to 18 years of age enrolled in this hospital. A tool for assessing the severity of the patient was developed, the aim of standardizing the procedure, while maintaining quality and safety. Guardian's satisfaction was assessed with a questionnaire sent after teleconsultations. Results: 255 teleconsultations were carried out with 140 different patients. Of the total consultations, 182 were from 99 patients that had performed the Real-Time Polymerase Chain Reaction (RT-PCR) test for the new coronavirus (SARS-Cov-2) or had direct contact with a person known to be positive for COVID-19. Only 26 (14%) were referred to an in-person consultation. No deaths, adverse events or delayed diagnosis were recorded. 86% of the patients who answered the satisfaction questionnaire were satisfied and 92% would use telemedicine again. Conclusion: This study presents an innovative implementation of a telemedicine program in a public and exclusively pediatric tertiary service, serving as a reference for future implementation in other public services in Brazil and developing countries.

Post-varicella arterial ischemic stroke in children and neurocognitive performance: a 4-year follow-up study

ABSTRACT Objective To analyze data from children who were previously healthy and presented with post-varicella arterial ischemic stroke upon arrival when admitted to the emergency room, with focus on the clinical/laboratory aspects, and neurocognitive performance after four-year follow-up. Methods Seven children presenting with arterial ischemic stroke after varicella were evaluated at pediatric emergency services in the city of São Paulo (SP), Brazil. Ischemic stroke was determined by magnetic resonance imaging/magnetic resonance angiography in a topography compatible with the areas supplied by the middle cerebral or internal carotid arteries. IgG-class antibodies against varicella zoster virus and varicella-zoster virus DNA by polymerase chain reaction in cerebrospinal fluid were tested. Patients with prothrombotic conditions were excluded. The Pediatric Stroke Outcome Measure was applied upon admission and 4-years after the stroke. Results All patients (age range: 1.3 to 4 years) included presented chickenpox 5.1 (±3.5) months before. All patients had analysis of anti-varicella-zoster-virus-IgG in cerebrospinal fluid, but only three (43%) had a positive result. Of the patients 43% had no vascular lesions identified in magnetic resonance angiography. All patients showed improvement in their sequela scores. After 4 years, five patients displayed good evolution in the Pediatric Stroke Outcome Measure, and only one patient presented with a score of 2 in the sensorimotor and cognition areas. No recurrence of arterial ischemic stroke was observed. Conclusion We reinforced the non-progressive course of post-varicella arterial ischemic stroke after 4-year follow-up. The presence of varicella-zoster-virus-DNA detected by polymerase chain reaction, and/or intrathecal IgG antibody against varicella zoster virus, and angiopathy location in magnetic resonance angiography were not determining for the diagnosis. Invasive tests, with low sensitivity, should be well considered in the diagnosis of post-varicella arterial ischemic stroke.

SARS-CoV-2 and rhinovirus infections: are there differences in clinical presentation, laboratory abnormalities, and outcomes in the pediatric population?

ABSTRACT This study aims to assess COVID-19 and other respiratory viruses in pediatric patients. Between April 17 and September 30, 2020, we collected 1,566 respiratory samples from 1,044 symptomatic patients who were younger than 18 years old to assess SARS-CoV-2 infection. Of these, 919 were analyzed for other respiratory pathogens (ORP). Patients with laboratory-confirmed COVID-19 or ORP were included. We evaluated 76 pediatric COVID-19 infections and 157 other respiratory virus infections. Rhinovirus occurred in 132/157 (84%). COVID-19 patients who were significantly older, had more fevers, headaches and pneumonia than those with ORP. The median white blood cell count was lower in patients with SARS-CoV-2 than in those with ORP (6,470 versus 8,170; p=0.02). COVID-19 patients had significantly worse symptoms than those with ORP.

Changing the view: impact of simulation-based mastery learning in pediatric tracheal intubation with videolaryngoscopy

Abstract Objective: To determine the effect of a training program using simulation-based mastery learning on the performance of residents in pediatric intubations with videolaryngoscopy. Method: Retrospective cohort study carried out in a tertiary pediatric hospital between July 2016 and June 2018 evaluating a database that included the performance of residents before and after training, as well as the outcome of tracheal intubations. A total of 59 pediatric residents were evaluated in the pre-training with a skills' checklist in the scenario with an intubation simulator; subsequently, they were trained individually using a simulator and deliberate practice in the department itself. After training, the residents were expected to have a minimum passing grade (90/100) in a simulated scenario. The success of the first attempted intubation, use of videolaryngoscopy, and complications in patients older than 1 year of age during the study period were also recorded in clinical practice. Results: Before training, the mean grade was 77.5/100 (SD 15.2), with only 23.7% (14/59) of residents reaching the minimum passing grade of 90/100. After training, 100% of the residents reached the grade, with an average of 94.9/100 (SD 3.2), p < 0.01, with only 5.1% (3/59) needing more practice time than that initially allocated. The success rate in the first attempt at intubation in the emergency department with videolaryngoscopy was 77.8% (21/27). The rate of adverse events associated with intubations was 26% (7/27), representing a serious event. Conclusions: Simulation-based mastery learning increased residents' skills related to intubation and allowed safe tracheal intubations with video laryngoscopy.

Differences in children and adolescents with SARS-CoV-2 infection: a cohort study in a Brazilian tertiary referral hospital

OBJECTIVES: To compare demographic/clinical/laboratory/treatments and outcomes among children and adolescents with laboratory-confirmed coronavirus disease 2019 (COVID-19). METHODS: This was a cross-sectional study that included patients diagnosed with pediatric COVID-19 (aged <18 years) between April 11, 2020 and April 22, 2021. During this period, 102/5,951 (1.7%) of all admissions occurred in neonates, children, and adolescents. Furthermore, 3,962 severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) detection samples were processed in patients aged <18 years, and laboratory-confirmed COVID-19 occurred in 155 (4%) inpatients and outpatients. Six/155 pediatric patients were excluded from the study. Therefore, the final group included 149 children and adolescents (n=97 inpatients and 52 outpatients) with positive SARS-CoV-2 results. RESULTS: The frequencies of sore throat, anosmia, dysgeusia, headache, myalgia, nausea, lymphopenia, pre-existing chronic conditions, immunosuppressive conditions, and autoimmune diseases were significantly reduced in children and adolescents (p<0.05). Likewise, the frequencies of enoxaparin use (p=0.037), current immunosuppressant use (p=0.008), vasoactive agents (p=0.045), arterial hypotension (p<0.001), and shock (p=0.024) were significantly lower in children than in adolescents. Logistic regression analysis showed that adolescents with laboratory-confirmed COVID-19 had increased odds ratios (ORs) for sore throat (OR 13.054; 95% confidence interval [CI] 2.750-61.977; p=0.001), nausea (OR 8.875; 95% CI 1.660-47.446; p=0.011), and lymphopenia (OR 3.575; 95% CI 1.355-9.430; p=0.010), but also had less hospitalizations (OR 0.355; 95% CI 0.138-0.916; p=0.032). The additional logistic regression analysis on patients with preexisting chronic conditions (n=108) showed that death as an outcome was significantly associated with pediatric severe acute respiratory syndrome (SARS) (OR 22.300; 95% CI 2.341-212.421; p=0.007) and multisystem inflammatory syndrome in children (MIS-C) (OR 11.261; 95% CI 1.189-106. 581; p=0.035). CONCLUSIONS: Half of the laboratory-confirmed COVID-19 cases occurred in adolescents. Individuals belonging to this age group had an acute systemic involvement of SARS-CoV-2 infection. Pediatric SARS and MIS-C were the most important factors associated with the mortality rate in pediatric chronic conditions with COVID-19.

Epidemiology of pediatric cardiopulmonary resuscitation / Epidemiologia da ressuscitação cardiopulmonar pediátrica

Abstract Objective: To analyze the main epidemiological aspects of prehospital and hospital pediatric cardiopulmonary resuscitation and the impact of scientific evidence on survival. Source of data: This was a narrative review of the literature published at PubMed/MEDLINE until January 2019 including original and review articles, systematic reviews, meta-analyses, annals of congresses, and manual search of selected articles. Synthesis of data: The prehospital and hospital settings have different characteristics and prognoses. Pediatric prehospital cardiopulmonary arrest has a three-fold lower survival rate than cardiopulmonary arrest in the hospital setting, occurring mostly at home and in children under 1 year. Higher survival appears to be associated with age progression, shockable rhythm, emergency medical care, use of automatic external defibrillator, high-quality early life support, telephone dispatcher-assisted cardiopulmonary resuscitation, and is strongly associated with witnessed cardiopulmonary arrest. In the hospital setting, a higher incidence was observed in children under 1 year of age, and mortality increased with age. Higher survival was observed with shorter cardiopulmonary resuscitation duration, occurrence on weekdays and during daytime, initial shockable rhythm, and previous monitoring. Despite the poor prognosis of pediatric cardiopulmonary resuscitation, an increase in survival has been observed in recent years, with good neurological prognosis in the hospital setting. Conclusions: A great progress in the science of pediatric cardiopulmonary resuscitation has been observed, especially in developed countries. The recognition of the epidemiological aspects that influence cardiopulmonary resuscitation survival may direct efforts towards more effective actions; thus, studies in emerging and less favored countries remains a priority regarding the knowledge of local factors.

Resumo Objetivo: Analisar os principais aspectos epidemiológicos da ressuscitação cardiopulmonar pediátrica pré-hospitalar e hospitalar e o impacto das evidências científicas na sobrevida. Fonte de dados: Revisão narrativa da literatura publicada em Pubmed/Medline até janeiro de 2019, inclusive artigos originais e de revisão, revisões sistemáticas, metanálises, anais de Congresso, além de busca manual dos artigos selecionados. Síntese dos dados: Os cenários pré-hospitalar e hospitalar apresentam características e prognósticos distintos. A parada cardiorrespiratória pré-hospitalar pediátrica apresenta sobrevida três vezes menor do que a hospitalar, ocorre em sua maioria nas residências e nos menores de um ano. A maior sobrevida parece estar associada a progressão da idade, ritmo chocável, atendimento por serviço médico de emergência, uso de desfibrilador externo automático, suporte básico de vida precoce de alta qualidade e orientação de ressuscitação cardiopulmonar via telefônica por atendente e está fortemente associada com parada cardiorrespiratória presenciada. No cenário hospitalar, observou-se maior incidência em menores de um ano e mortalidade crescente com a idade. Maior sobrevida foi observada quanto a menor duração da ressuscitação cardiopulmonar, ocorrência em dias da semana e período diurno, ritmo chocável inicial e monitoração prévia. Apesar do prognóstico reservado da ressuscitação cardiopulmonar pediátrica, observou-se nos últimos anos incremento da sobrevida com bom prognóstico neurológico no cenário hospitalar. Conclusões: Houve grande avanço na ciência da ressuscitação cardiopulmonar pediátrica, especialmente em países desenvolvidos. O reconhecimento dos aspectos epidemiológicos que influenciam a sobrevida da ressuscitação cardiopulmonar pode direcionar esforços para ações mais efetivas. Assim, a pesquisa em países emergentes e menos favorecidos persiste como prioridade no conhecimento de fatores locais.

Severe clinical spectrum with high mortality in pediatric patients with COVID-19 and multisystem inflammatory syndrome

OBJECTIVES: To assess the outcomes of pediatric patients with laboratory-confirmed coronavirus disease (COVID-19) with or without multisystem inflammatory syndrome in children (MIS-C). METHODS: This cross-sectional study included 471 samples collected from 371 patients (age<18 years) suspected of having severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The study group comprised 66/371 (18%) laboratory-confirmed pediatric COVID-19 patients: 61 (92.5%) patients tested positive on real-time reverse transcription-polymerase chain reaction tests for SARS-CoV-2, and 5 (7.5%) patients tested positive on serological tests. MIS-C was diagnosed according to the criteria of the Center for Disease Control. RESULTS: MIS-C was diagnosed in 6/66 (9%) patients. The frequencies of diarrhea, vomiting, and/or abdominal pain (67% vs. 22%, p=0.034); pediatric SARS (67% vs. 13%, p=0.008); hypoxemia (83% vs. 23%, p=0.006); and arterial hypotension (50% vs. 3%, p=0.004) were significantly higher in patients with MIS-C than in those without MIS-C. The frequencies of C-reactive protein levels >50 mg/L (83% vs. 25%, p=0.008) and D-dimer levels >1000 ng/mL (100% vs. 40%, p=0.007) and the median D-dimer, troponin T, and ferritin levels (p<0.05) were significantly higher in patients with MIS-C. The frequencies of pediatric intensive care unit admission (100% vs. 60%, p=0.003), mechanical ventilation (83% vs. 7%, p<0.001), vasoactive agent use (83% vs. 3%, p<0.001), shock (83% vs. 5%, p<0.001), cardiac abnormalities (100% vs. 2%, p<0.001), and death (67% vs. 3%, p<0.001) were also significantly higher in patients with MIS-C. Similarly, the frequencies of oxygen therapy (100% vs. 33%, p=0.003), intravenous immunoglobulin therapy (67% vs. 2%, p<0.001), aspirin therapy (50% vs. 0%, p<0.001), and current acute renal replacement therapy (50% vs. 2%, p=0.002) were also significantly higher in patients with MIS-C. Logistic regression analysis showed that the presence of MIS-C was significantly associated with gastrointestinal manifestations [odds ratio (OR)=10.98; 95%CI (95% confidence interval)=1.20-100.86; p=0.034] and hypoxemia [OR=16.85; 95%CI=1.34-211.80; p=0.029]. Further univariate analysis showed a positive association between MIS-C and death [OR=58.00; 95%CI=6.39-526.79; p<0.0001]. CONCLUSIONS: Pediatric patients with laboratory-confirmed COVID-19 with MIS-C had a severe clinical spectrum with a high mortality rate. Our study emphasizes the importance of investigating MIS-C in pediatric patients with COVID-19 presenting with gastrointestinal involvement and hypoxemia.

Sedation and analgesia for procedures in the pediatric emergency room / Sedação e analgesia para procedimentos no pronto-socorro de pediatria

Abstract Objective: Children and adolescents often require sedation and analgesia in emergency situations. With the emergence of new therapeutic options, the obsolescence of others, and recent discoveries regarding already known drugs, it became necessary to review the literature in this area. Data sources: Non-systematic review in the PubMed database of studies published up to December 2016, including original articles, review articles, systematic reviews, and meta-analyses. References from textbooks, publications from regulatory agencies, and articles cited in reviews and meta-analyses through active search were also included. Data synthesis: Based on current literature, the concepts of sedation and analgesia, the necessary care with the patient before, during, and after sedoanalgesia, and indications related to the appropriate choice of drugs according to the procedure to be performed and their safety profiles are presented. Conclusions: The use of sedoanalgesia protocols in procedures in the pediatric emergency room should guide the professional in the choice of medication, the appropriate material, and in the evaluation of discharge criteria, thus assuring quality in care.

Resumo Objetivo: Crianças e adolescentes necessitam frequentemente de sedação e analgesia em situações de emergência. Com o surgimento de novas opções terapêuticas, a obsolescência de outras e descobertas recentes das drogas já conhecidas, fez-se necessário uma nova revisão da literatura nessa área. Fontes dos dados: Revisão não sistemática na base de dados PubMed de estudos publicados até dezembro de 2016, inclusive artigos originais, artigos de revisão, revisões sistemáticas e metanálises. Também foram incluídos referências de livros-texto, publicações de agências reguladoras, além de artigos citados nas revisões e metanálises através de busca ativa. Síntese dos dados: Com base na literatura atual, são apresentados os conceitos de sedação e analgesia, os cuidados necessários com o paciente antes, durante e após a sedoanalgesia, além de indicações quanto à escolha apropriada dos fármacos de acordo com o procedimento a ser feito e o perfil de segurança desses. Conclusões: O emprego de protocolos de sedoanalgesia em procedimentos no pronto-socorro pediátrico deve orientar o profissional na escolha da medicação, do material adequado e na avaliação dos critérios de alta e garantir, assim, qualidade na assistência.

High-fidelity simulation versus case-based discussion for teaching medical students in Brazil about pediatric emergencies

OBJECTIVE: To compare high-fidelity simulation with case-based discussion for teaching medical students about pediatric emergencies, as assessed by a knowledge post-test, a knowledge retention test and a survey of satisfaction with the method. METHODS: This was a non-randomized controlled study using a crossover design for the methods, as well as multiple-choice questionnaire tests and a satisfaction survey. Final-year medical students were allocated into two groups: group 1 participated in an anaphylaxis simulation and a discussion of a supraventricular tachycardia case, and conversely, group 2 participated in a discussion of an anaphylaxis case and a supraventricular tachycardia simulation. Students were tested on each theme at the end of their rotation (post-test) and 4-6 months later (retention test). RESULTS: Most students (108, or 66.3%) completed all of the tests. The mean scores for simulation versus case-based discussion were respectively 43.6% versus 46.6% for the anaphylaxis pre-test (p=0.42), 63.5% versus 67.8% for the post-test (p=0.13) and 61.5% versus 65.5% for the retention test (p=0.19). Additionally, the mean scores were respectively 33.9% versus 31.6% for the supraventricular tachycardia pre-test (p=0.44), 42.5% versus 47.7% for the post-test (p=0.09) and 41.5% versus 39.5% for the retention test (p=0.47). For both themes, there was improvement between the pre-test and the post-test (p<0.05), and no significant difference was observed between the post-test and the retention test (p>0.05). Moreover, the satisfaction survey revealed a preference for simulation (p<0.001). CONCLUSION: As a single intervention, simulation is not significantly different from case-based discussion in terms of acquisition and retention of knowledge but is superior in terms of student satisfaction. .

Association between participation and compliance with Continuing Medical Education and care production by physicians: a cross-sectional study / Associação entre participação e cumprimento de um programa de Educação Médica Continuada e produção assistencial dos médicos: estudo transversal

Objective Physician participation in Continuing Medical Education programs may be influenced by a number of factors. To evaluate the factors associated with compliance with the Continuing Medical Education requirements at a private hospital, we investigated whether physicians’ activity, measured by volumes of admissions and procedures, was associated with obtaining 40 Continuing Medical Education credits (40 hours of activities) in a 12-month cycle. Methods In an exclusive and non-mandatory Continuing Medical Education program, we collected physicians’ numbers of hospital admissions and numbers of surgical procedures performed. We also analyzed data on physicians’ time since graduation, age, and gender. Results A total of 3,809 credentialed, free-standing, private practice physicians were evaluated. Univariate analysis showed that the Continuing Medical Education requirements were more likely to be achieved by male physicians (odds ratio 1.251; p=0.009) and who had a higher number of hospital admissions (odds ratio 1.022; p<0.001). Multivariate analysis showed that age and number of hospital admissions were associated with achievement of the Continuing Medical Education requirements. Each hospital admission increased the chance of achieving the requirements by 0.4%. Among physicians who performed surgical procedures, multivariate analysis showed that male physicians were 1.3 time more likely to achieve the Continuing Medical Education requirements than female physicians. Each surgical procedure performed increased the chance of achieving the requirements by 1.4%. Conclusion The numbers of admissions and number of surgical procedures performed by physicians at our hospital were associated with the likelihood of meeting the Continuing Medical Education requirements. These findings help to shed new light on our Continuing Medical Education program. .

Objetivo A participação de médicos em programas de Educação Médica Continuada pode ser influenciada por inúmeros fatores. Para avaliar os fatores associados ao cumprimento dos requisitos para Educação Médica Continuada em um hospital privado, investigamos se a atividade médica, medida por volume de internações e procedimentos, esteve relacionada à obtenção de 40 créditos (40 horas-aula) em um ciclo do programa de 12 meses. Métodos Em um programa exclusivo e não obrigatório de Educação Médica Continuada, coletamos o número de admissões e de procedimentos realizados por médico. Analisamos dados como tempo de formado, idade e sexo. Resultados Foram analisados dados de 3.809 médicos credenciados e autônomos. A análise univariada mostrou que os requisitos de Educação Médica Continuada eram mais preenchidos por médicos do sexo masculino (odds ratio de 1,251; p=0,009) e que eles apresentavam números de internações mais significativos (odds ratio de 1,022; p<0,001). A análise multivariada mostrou que idade e número de admissões estiveram associados ao cumprimento das metas estabelecidas. Cada admissão aumentou a chance de atingir a meta em 0,4%. Entre os que realizaram procedimentos cirúrgicos, a análise multivariada mostrou que médicos do sexo masculino eram 1,3 vez mais propensos a atingir a meta estabelecida que seus pares do sexo feminino. Cada procedimento cirúrgico realizado elevou a chance de atingir a meta em 1,4%. Conclusão O número de admissões e de procedimentos cirúrgicos realizados por médicos em nosso hospital foi associado à probabilidade de alcançar a meta de Educação Médica Continuada. Estes achados lançaram uma nova luz sobre o nosso programa de Educação Médica Continuada. .

Morbidity due trauma in children of the community of Paraisopolis, São Paulo, Brazil / Morbidade por trauma em crianças moradoras da comunidade de Paraisópolis, São Paulo, Brasil / Morbidade por trauma em crianças moradoras da comunidade de Paraisópolis, São Paulo, Brasil

Objective : To identify the factors that determine unintentional injuries in children living in the community of Paraisopolis, in the city of São Paulo, Brazil. Methods : A cross-sectional and non-controlled study. Data collected during 4 consecutive months through questionnaires filled out for the Einstein Program in Paraisopolis Community included identification of the patient and his/her family, scholarity level, housing conditions, storage of hazardous products, access to the streets and concrete slab ceilings, supervision, and trauma mechanism involved. The observed data were treated as absolute and relative frequencies; χ2, Fisher’s exact test, Student’s t test, and Mann-Whitney’s tests were implemented, with a significance level of 5% (p<0.05). Results : A total of 1,490 questionnaires were analyzed. There was a predominance of trauma within boys (59.6%) and the medium age was 5.2 years. The predominant educational level of the parents was incomplete junior school education. The main caregiver identified was the mother (69.4%). Among the children that suffered trauma, 56.4% belonged to large families (≥6 people), lived in houses up to three rooms, and a family income up to R$ 1,000.00 (76.6%). Easy access to hazardous materials was considerable and free access to concrete slab ceilings was reported in 92.8% of the cases. The main trauma mechanisms were falls and burns. In this study, the child victim of a fall was aged under 5 years. Conclusion : Small children that live in a hazardous environment have a significant tendency to suffering trauma .

Objetivo : Identificar os fatores determinantes de lesões não intencionais na população pediátrica residente na comunidade de Paraisópolis, em São Paulo. Métodos : Estudo transversal, não controlado. Os dados coletados durante 4 meses consecutivos, por meio de questionários preenchidos para o Programa Einstein na Comunidade de Paraisópolis foram: identificação do paciente e familiares, escolaridade, condições da moradia, armazenamento de produtos perigosos, acesso à rua e à laje, supervisão e mecanismo de trauma envolvido. Os dados observados foram tratados por meio de frequências absolutas e relativas; foram empregados os testes χ2, exato de Fisher, t de Student Mann-Whitney, com nível de significância de 5% (p<0,05). Resultados : Foram analisados 1.490 questionários. Houve predominância de traumatismos entre meninos (59,6%) e a média de idade foi de 5,2 anos. Ensino Fundamental incompleto foi o nível de escolaridade predominante entre os pais. O cuidador principal identificado foi a mãe (69,4%). Das crianças que sofreram trauma, 56,4% pertenciam a famílias numerosas (≥6 pessoas), moravam em casas de até três cômodos com renda familiar de até R$ 1.000,00 (76,6%). O acesso fácil a substâncias perigosas foi considerável, e o livre acesso a lajes foi relatado em 92,8% dos casos. Os principais mecanismos de trauma foram quedas e queimaduras. Neste estudo, a criança vítima de queda tinha menos de 5 anos de idade. Conclusão : Crianças pequenas que vivem em um ambiente de risco apresentam tendência significativa a sofrer eventos traumáticos. .

Mortalidade em hospital secundário pediátrico na Libéria pós-conflito em 2009 / Mortality in a pediatric secondary-care hospital in post-conflict Liberia in 2009

OBJETIVO: Descrever e analisar as causas de morte em um hospital secundário pediátrico (administrado pelos Médicos sem Fronteiras) na Monróvia, Libéria, 6 anos após o fim da guerra civil, para determinar a qualidade dos cuidados e a mortalidade em uma realidade com recursos limitados. MÉTODOS: Os dados foram coletados retrospectivamente de março a outubro de 2009. Os prontuários e dados laboratoriais foram revisados para verificar a causa de morte. Além disso, prontuários de pacientes com mais de 1 mês de vida com causa de morte infecciosa foram analisados, para avaliar a presença de choque séptico descompensado ou choque séptico refratário a fluidos. RESULTADOS: Do total de 8.254 pacientes admitidos, 531 morreram, com taxa de mortalidade de 6,4%. Noventa por cento dos óbitos ocorreram em crianças <5 anos. A maioria das mortes ocorreu nas primeiras 24 horas de internação. A causa principal (76%) foi doença infecciosa. Apresentaram choque séptico 78 (23,6%) pacientes com mais de 1 mês de idade e doença infecciosa, e 28 (8,6%) apresentaram choque séptico descompensado ou refratário a fluidos. CONCLUSÃO: Desde o fim da devastadora guerra civil na Libéria, o Island Hospital tem melhorado a qualidade de cuidado e diminuído a taxa de mortalidade, apesar de atuar com recursos limitados. Com base nos dados disponíveis, a mortalidade do Island Hospital aparenta ser menor do que em outras instituições liberianas e africanas, e semelhante a de outros hospitais administrados pelos Médicos sem Fronteiras na África. A explicação para esse fato é o apoio logístico e financeiro dos Médicos sem Fronteiras. A maior carga de mortalidade está relacionada a doenças infecciosas e condições neonatais. A mortalidade por sepse variou entre diferentes infecções. Isso sugere que a mortalidade ainda pode ser reduzida ao se melhorarem o tratamento e os cuidados neonatais.

OBJECTIVE: To describe and analyze the causes of death in a pediatric secondary-care hospital (run by Médecins sans Frontières), in Monrovia, Liberia, 6 years post-civil war, to determine the quality of care and mortality in a setting with limited resources. METHODS: Data were retrospectively collected from March 2009 to October 2009. Patient charts and laboratory records were reviewed to verify cause of death. Additionally, charts of patients aged over 1 month with an infectious cause of death were analyzed for decompensated septic shock, or fluid-refractory septic shock. RESULTS: Of 8,254 admitted pediatric patients, 531 died, with a mortality rate of 6.4%. Ninety percent of deaths occurred in children <5 years old. Most deaths occurred within 24 hours of admission. The main cause of death (76%) was infectious disease. Seventy-eight (23.6%) patients >1 month old with infectious disease met the criteria for septic shock, and 28 (8.6%) for decompensated or fluid-refractory septic shock. CONCLUSION: Since the end of Liberia's devastating civil war, Island Hospital has improved care and mortality outcomes, despite operating with limited resources. Based on the available data, mortality in Island Hospital appears to be lower than that of other Liberian and African institutions and similar to other hospitals run by Médecins sans Frontières across Africa. This can be explained by the financial and logistic support of Médecins sans Frontières. The highest mortality burden is related to infectious diseases and neonatal conditions. The mortality of sepsis varied among different infections. This suggests that further mortality reduction can be obtained by tackling sepsis management and improving neonatal care.

Early-life weight and weight gain as predictors of obesity in Brazilian adolescents

OBJECTIVE: To test whether weight and the weight gain rate during different age periods are associated with being overweight/obese at 10 years of age. METHODS: A nested case-control study was performed in a clinical historic cohort that was selected based on medical records from the Albert Einstein Hospital Social Program in São Paulo, Brazil. A sample of 378 eutrophic and overweight/obese children was analyzed. RESULTS: After adjusting for birth weight and gestational age, the likelihood of being overweight/obese at 10 years of age was 4.04-fold greater when progressing from one quartile of weight gain to the immediately superior quartile in the first semester of life and 3.24-fold greater when this occurred from 2-5 years of age. A one-quartile change in weight gain in the first semester was associated with a 0.5 z-score increase in BMI at age 10. A robust independent effect of weight at age 5 confirmed that earlier weight gain was an important predictor. CONCLUSIONS: The amount of weight gain during the first 6 months of life and between 2 and 5 years of age and weight at age 5 were important predictors of overweight/obesity at 10 years of age. .

Parental smoking patterns and their association with wheezing in children

OBJECTIVE: To investigate parental smoking patterns and their association with wheezing in children. METHODS: We performed a case-control study that included 105 children between 6 and 23 months of age who were divided into two groups: cases (children with 3 previous episodes of wheezing) and controls (healthy children without wheezing). The children's exposure to cigarette smoking was estimated using a questionnaire completed by the mothers and by the children's urinary cotinine levels. RESULTS: Based on both the questionnaire results and cotinine levels, exposure to cigarette smoking was higher in the households of cases in which the incidence of maternal smoking was significantly higher than that of paternal smoking. Children in this group were more affected by maternal smoking and by the total number of cigarettes smoked inside the house. Additionally, the questionnaire results indicated that the risk of wheezing was dose dependent. The presence of allergic components, such as atopic dermatitis and siblings with allergic rhinitis and asthma, greatly increased the odds ratio when wheezing was associated with cotinine levels. CONCLUSION: Children exposed to tobacco smoke have an increased risk of developing wheezing syndrome. This risk increases in association with the number of cigarettes smoked inside the house and the presence of other allergic components in the family. .