Ultrasound-Guided Regional Anesthesia of the Femoral Nerve in the Pediatric Emergency Department.

OBJECTIVES: Femur fractures are painful, and use of systemic opioids and other sedatives can be dangerous in pediatric patients. The fascia iliaca compartment nerve block and femoral nerve block are regional anesthesia techniques to provide analgesia by anesthetizing the femoral nerve. They are widely used in adult patients and are associated with good effect and reduced opioid use. Ultrasound (US) guidance of nerve blocks can increase their safety and efficacy. We sought to report on the use and safety of US-guided regional anesthesia of the femoral nerve performed by emergency physicians for femur fractures in 6 pediatric emergency departments. METHODS: Records were queried at 6 pediatric EDs across North America to identify patients with femur fractures managed with US-guided regional anesthesia of the femoral nerve between January 1, 2016, and May 1, 2021. Data were abstracted regarding demographics, injury pattern, nerve block technique, and analgesic use before and after nerve block. RESULTS: Eighty-five cases were identified. Median age was 5 years (interquartile range, 2-9 years). Most patients were male and had sustained blunt trauma (59% low-mechanism falls). Ninety-four percent of injuries were managed operatively. Most patients (79%) received intravenous opioid analgesia before their nerve block. Ropivacaine was the most common local anesthetic used (69% of blocks). No procedural complications or adverse effects were identified. CONCLUSIONS: Ultrasound-guided regional anesthesia of the femoral nerve is widely performed and can be performed safely on pediatric patients by emergency physicians and trainees in the pediatric emergency department.

Point-of-Care Ultrasound-Guided Serratus Anterior Plane Block for Chest Tube Placement in a Spontaneous Pneumothorax.

ABSTRACT: Chest tube placement is a common procedure in the pediatric emergency department. There is general emergency medicine literature as well as pediatric cardiac surgery literature supporting the use of an ultrasound-guided serratus anterior plane block for regional anesthesia with no prior pediatric emergency medicine studies to our knowledge. This case describes a pediatric patient who required chest tube placement twice for a pneumothorax and describes his preference for the nerve block over the more commonly used procedural sedation.

Point-of-Care Ultrasound Use by EMS Providers in Out-of-Hospital Cardiac Arrest.

AIM: Paramedics received training in point-of-care ultrasound (POCUS) to assess for cardiac contractility during management of medical out-of-hospital cardiac arrest (OHCA). The primary outcome was the percentage of adequate POCUS video acquisition and accurate video interpretation during OHCA resuscitations. Secondary outcomes included POCUS impact on patient management and resuscitation protocol adherence. METHODS: A prospective, observational cohort study of paramedics was performed following a four-hour training session, which included a didactic lecture and hands-on POCUS instruction. The Prehospital Echocardiogram in Cardiac Arrest (PECA) protocol was developed and integrated into the resuscitation algorithm for medical non-shockable OHCA. The ultrasound (US) images were reviewed by a single POCUS expert investigator to determine the adequacy of the POCUS video acquisition and accuracy of the video interpretation. Change in patient management and resuscitation protocol adherence data, including end-tidal carbon dioxide (EtCO2) monitoring following advanced airway placement, adrenaline administration, and compression pauses under ten seconds, were queried from the prehospital electronic health record (EHR). RESULTS: Captured images were deemed adequate in 42/49 (85.7%) scans and paramedic interpretation of sonography was accurate in 43/49 (87.7%) scans. The POCUS results altered patient management in 14/49 (28.6%) cases. Paramedics adhered to EtCO2 monitoring in 36/36 (100.0%) patients with an advanced airway, adrenaline administration for 38/38 (100.0%) patients, and compression pauses under ten seconds for 36/38 (94.7%) patients. CONCLUSION: Paramedics were able to accurately obtain and interpret cardiac POCUS videos during medical OHCA while adhering to a resuscitation protocol. These findings suggest that POCUS can be effectively integrated into paramedic protocols for medical OHCA.

Randomized Controlled Trial of Point-of-Care Ultrasound Education for the Recognition of Tension Pneumothorax by Paramedics in Prehospital Simulation.

OBJECTIVE: The primary goal of this study was to determine if ultrasound (US) use after brief point-of-care ultrasound (POCUS) training on cardiac and lung exams would result in more paramedics correctly identifying a tension pneumothorax (TPTX) during a simulation scenario. METHODS: A randomized controlled, simulation-based trial of POCUS lung exam education investigating the ability of paramedics to correctly diagnose TPTX was performed. The US intervention group received a 30-minute cardiac and lung POCUS lecture followed by hands-on US training. The control group did not receive any POCUS training. Both groups participated in two scenarios: right unilateral TPTX and undifferentiated shock (no TPTX). In both scenarios, the patient continued to be hypoxemic after verified intubation with pulse oximetry of 86%-88% and hypotensive with a blood pressure of 70/50. Sirens were played at 65 decibels to mimic prehospital transport conditions. A simulation educator stated aloud the time diagnoses were made and procedures performed, which were recorded by the study investigator. Paramedics completed a pre-survey and post-survey. RESULTS: Thirty paramedics were randomized to the control group; 30 paramedics were randomized to the US intervention group. Most paramedics had not received prior US training, had not previously performed a POCUS exam, and were uncomfortable with POCUS. Point-of-care US use was significantly higher in the US intervention group for both simulation cases (P <.001). A higher percentage of paramedics in the US intervention group arrived at the correct diagnosis (77%) for the TPTX case as compared to the control group (57%), although this difference was not significantly different (P = 0.1). There was no difference in the correct diagnosis between the control and US intervention groups for the undifferentiated shock case. On the post-survey, more paramedics in the US intervention group were comfortable with POCUS for evaluation of the lung and comfortable decompressing TPTX using POCUS (P <.001). Paramedics reported POCUS was within their scope of practice. CONCLUSIONS: Despite being novice POCUS users, the paramedics were more likely to correctly diagnose TPTX during simulation after a brief POCUS educational intervention. However, this difference was not statistically significant. Paramedics were comfortable using POCUS and felt its use improved their TPTX diagnostic skills.

Performance of Emergency Medical Service Providers in Pediatric and Adult Simulation of Unstable Supraventricular Tachycardia.

OBJECTIVE: The aim of the study was to compare emergency medical service resuscitation of pediatric and adult high-fidelity manikins in unstable supraventricular tachycardia. The primary objective was time to cardioversion. The secondary objective was to assess if the cardioversion was synchronized at the correct dosage for the manikin's weight. METHODS: Emergency medical service providers were voluntarily enrolled as part of an emergency medical service training program. Participants were randomized to either a pediatric or adult resuscitation as their study scenario. They then completed the second resuscitation as part of the training program. Participants completed presurvey and postsurvey. Resuscitations were videotaped and analyzed by a blinded reviewer. The study was powered to detect a 60-second difference in performance between pediatric and adult scenarios with a ß of 0.8 and 2-tailed α of 0.05 using an independent-samples t test. RESULTS: A total of 37 participants were enrolled. Participants in the pediatric arm had a longer mean time to cardioversion, but the difference was not statistically significant. The mean delay to cardioversion in the pediatric scenario was 34 seconds (197 vs 163 seconds; difference 95% confidence interval [CI], -5 to 73 seconds; P = 0.09). There was no significant difference in the percentage of participants who administered a correct dose (32% vs 50%; difference 95% CI, -50% to 13%; P = 0.75) or regarding synchronization of cardioversion (74% vs 83%; difference 95% CI, -36% to 17%; P = 0.42). CONCLUSIONS: Emergency medical service providers did not have a significant difference in time to cardioversion between pediatric and adult unstable supraventricular tachycardia simulations.

Coral snake bites and envenomation in children: a case series.

OBJECTIVE: North America is home to 2 families of venomous snakes, Crotalinae (pit viper family) and Elapidae (coral snake family). Although there are several published reports describing and reviewing the management of pit viper snakebites in children, there are no recent similar publications detailing the clinical course and management of coral snake envenomation. METHODS: Our case series describes the hospital course of children with coral snake bites admitted to our regional pediatric intensive care. We also reviewed prior published case reports of coral snake bites in the United States. RESULTS: We identified 4 patients with either confirmed or suspected coral snake envenomation from our hospital's records. In 2 cases, the snakebite occurred after apparent provocation. Antivenom was administered to 3 patients. The regional venom response team was consulted for management advice and supplied the antivenom. One patient had a prolonged hospital course, which was complicated by respiratory failure, bulbar palsy, and ataxia. All survived to discharge. CONCLUSIONS: Admission to pediatric intensive care is warranted after all Eastern coral snake bites. A specialized regional or national venom response team can be a useful resource for management advice and as a source of antivenom.