Pediatric Emergency Medicine Point-of-Care Ultrasound for the Diagnosis of Intussusception.

BACKGROUND: Delayed diagnosis of intussusception can lead to air enema failure and increased morbidity. There are limited studies reporting the accuracy of pediatric emergency medicine (PEM) physician point-of-care ultrasound (POCUS) in diagnosing intussusception. OBJECTIVES: The primary objective was to evaluate the accuracy of PEM POCUS in identifying ileocolic intussusception. The secondary objective was to identify factors associated with air enema failure. METHODS: This was a retrospective study of children who underwent POCUS for suspected intussusception in a pediatric emergency department between January 2001 and December 2015. Patients were included if a pediatric radiologist confirmed the POCUS examination interpretation by image review, radiology department ultrasound, or air enema. Age, symptom duration, recurrent intussusception, and location of intussusception were examined as factors for air enema failure. RESULTS: One hundred and two POCUS examinations were completed on 101 patients who met the inclusion criteria. The mean age of patients was 22 months. Of 75 patients with intussusception, 72 were detected with POCUS. PEM POCUS had a sensitivity of 96.0% (95% confidence interval [CI] 91.6-100.0%), specificity of 92.6% (95% CI 82.7-100.0%), positive predictive value of 97.3% (95% CI 93.6-100.0%), and negative predictive value of 89.3% (95% CI 77.8-100.0%). Air enema failure was associated with intussusception distal to the splenic flexure (odds ratio = 10.00 [95% CI 2.81-35.61]; p < 0.01) and age <6 months (OR = 6.83 [95% CI 1.94-24.09]; p < 0.01). CONCLUSION: PEM POCUS identifies intussusception with high sensitivity and specificity. Patients <6 months old or with intussusception distal to the splenic flexure had a higher risk of air enema failure.

Increasing ED Use of Jet Injection of Lidocaine for IV-Related Pain Management.

BACKGROUND AND OBJECTIVE: Venipuncture is a leading cause of procedural pain for children. Jet injection of lidocaine (JIL; J-Tip) has been demonstrated to be effective in controlling intravenous (IV) placement-related pain and, due to its rapid onset, is particularly suited to emergency department (ED) use. Our objective was to increase JIL use with IV placements in our ED from 11% at baseline to 50% within 12 months. METHODS: We initiated the project at our urban, tertiary pediatric ED in July 2014. We surveyed medical and nursing teams to identify barriers to JIL use. We initiated changes at monthly intervals: (1) order set changes, (2) online education, (3) hands-on workshops, (4) improved accessibility, (5) standing order policy revision, and (6) reminders. We collected biweekly data on IV placements for all ED patients, except level 1 (critical) triage patients. We used standard quality improvement methodology and statistical process control for statistical analysis. RESULTS: JIL use with IV placement increased to 54% over 7 months and has remained >50% for >12 months. For all eligible IV placements (n = 12 791), 76.4% of those where JIL was used were successful on the first attempt compared with 75.8% without JIL (χ21degrees of freedom = 0.33, P = .56), with no significant difference in the success at IV placement. CONCLUSIONS: We sustainably increased JIL use with IV placement. The use of JIL was not associated with a difference in first-attempt IV placement success rates. We are expanding the project to other parts of the institution.

Preparing for pediatric emergencies: drugs to consider.

This clinical report provides current recommendations regarding the selection and use of drugs in preparation for pediatric emergencies. It is not intended to be a comprehensive list of all medications that may be used in all emergencies. When possible, dosage recommendations are consistent with those used in current emergency references such as the Advanced Pediatric Life Support and Pediatric Advanced Life Support textbooks and the recently revised American Heart Association resuscitation guidelines.

The use of high-dose epinephrine for patients with out-of-hospital cardiopulmonary arrest refractory to prehospital interventions.

OBJECTIVE: To determine if high-dose epinephrine (HDE) used during out-of-hospital cardiopulmonary arrest refractory to prehospital interventions improves return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcomes. METHODS: A multicenter randomized controlled trial was conducted between May 1991 and October 1996 to compare the effectiveness of HDE versus standard-dose epinephrine (SDE) in patients having out-of-hospital cardiopulmonary arrest refractory to prehospital resuscitation efforts. Cardiopulmonary arrest was classified as "medical" or "traumatic." Two hundred thirty patients were enrolled in 7 pediatric emergency departments. Ages ranged from newborn to 22 years. Seventeen patients met exclusion criteria. Patients were assigned to receive HDE (0.1 mg/kg for the initial dose and 0.2 mg/kg for subsequent doses) or SDE (0.01 mg/kg). The main end points evaluated were return of spontaneous circulation, 24-hour survival, discharge survival, and neurological outcome. RESULTS: One hundred twenty-seven patients received HDE (32 trauma patients), and 86 patients received SDE (27 trauma patients). Among medical patients, 24 (25%) of 95 experienced return of spontaneous circulation in the HDE group as compared with 9 (15%) of 59 in the SDE group (P = 0.14, chi2 = 2.17, relative risk = 1.66 [0.83-3.31]). Sixteen (17%) of 95 HDE patients and 5 (8%) of 59 SDE patients survived at least 24 hours (P = 0.14, chi2 = 2.16, relative risk = 1.99 [0.77-5.14]). Nine survivors to discharge received HDE, and 2 received SDE (P = 0.21, Fisher exact test, relative risk = 2.75 [0.61-12.28]). There were no long-term survivors among the trauma patients. Eight of 11 long-term survivors had severe neurological outcomes defined by the Glasgow Outcome Scale (2/2 SDE, 6/9 HDE; P = 0.51, Fisher exact test). CONCLUSION: HDE does not improve or diminish return of spontaneous circulation, 24-hour survival, long-term survival, or neurological outcome compared with SDE in out-of-hospital cardiopulmonary arrest.