Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Pediatric Sedation Complications.

Introduction: Ketamine and propofol are commonly used agents for sedation in the pediatric emergency department (PED). While these medications routinely provide safe sedations, there are side effects providers should be able to recognize and manage. Currently, no pediatric sedation simulations exist in the literature. Methods: We created two sedation simulation cases for learners, including pediatric emergency medicine (PEM) fellows, working in the PED: case 1, a 12-year-old male with a shoulder dislocation requiring reduction under propofol sedation, and case 2, a forearm fracture requiring reduction under ketamine sedation. Learner actions included setting up equipment for sedations, dosing medications correctly, and managing complications. Additionally, in case 2, learners assigned an American Society of Anesthesiologists classification and selected the appropriate candidate for PED sedation from amongst three patients. A debrief followed the cases. Next, a didactic presentation reinforced concepts discussed in the debrief. Participants then completed an evaluation of the simulation. Results: Fifty-eight emergency medicine residents and PEM fellows across four sites at three institutions participated. Participants scored the simulations and the debriefing session on a 5-point Likert scale. Learners rated the scenario as clinically relevant (M = 4.37) and effective at improving their comfort level in caring for critically ill patients (M = 4.36). Learners felt the debrief provided valuable learning (M = 4.40) and was a safe learning environment (M = 4.50). Discussion: These cases can be utilized as resources for learners in any emergency department and can be tailored to any training background of learner providing sedation.

Standardization of the management of pediatric urolithiasis in the emergency department.

INTRODUCTION: The incidence of urolithiasis in the pediatric population is rising and medical expulsive therapy (MET) using alpha-adrenergic antagonists has been found to be effective in aiding in the passage of ureteral stones in children. A prior review of patients presenting to our quaternary children's hospital with urolithiasis found only 54 % were prescribed MET and these patients had increased rates of spontaneous stone passage. Thus, an ED urolithiasis management protocol was created to standardize evaluation and care of children with suspected urolithiasis. OBJECTIVE: To compare management of children with urolithiasis presenting to the ED before and after urolithiasis management protocol implementation. METHODS: This is a retrospective review of patients with urolithiasis who presented to our children's ED from 2011 to 2022. The primary outcome was rate of MET prescribing before and after pathway implementation in July 2017, thus the pre-implementation group comprises patients who presented to the ED from July 2011 to July 2017, and the post-protocol group includes those who presented from August 2017 to April 2022. Secondary outcomes included CT utilization in the ED, surgical intervention rate, proportion with spontaneous stone passage, and frequency of urology consultation. Two-sample t-test and Fisher's exact test were used to compare the outcomes of interest before and after protocol implementation. RESULTS: Of 337 patients who presented to the ED after protocol implementation, 120 met inclusion criteria. When comparing outcomes before and after implementation of the protocol, there was significantly decreased use of CT scans (79 % vs 50 %, p < 0.0001) and increased prescribing of MET (54 % vs 82 %, p < 0.0001). There was a significant decrease in opioids prescribed (44 % vs 26.7 %, p = 0.0040), and an increased rate of spontaneous stone passage (34 % vs 46 %, p = 0.0483). Lastly, there was a significant reduction in the rate of surgery for stone management after the implementation of protocol (35 % vs 17 %, p = 0.0020) DISCUSSION: As the ED is the primary site of presentation for many children with urolithiasis, standardization of evaluation and management provides an opportunity to improve outcomes in this population. We found that implementation of an ED urolithiasis management protocol was associated with decreased use of CT scans, decreased opioid prescribing, increased spontaneous stone passage, and decreased rate of surgical management for children with ureteral stones. CONCLUSIONS: This study demonstrates the positive impact of standardizing care for children presenting to the ED with urolithiasis.

Pediatric Emergency Medicine Didactics and Simulation: JumpSTART Secondary Triage for Mass Casualty Incidents.

Mass casualty incidents (MCI), particularly involving pediatric patients, are high-risk, low-frequency occurrences that require exceptional emergency arrangements and advanced preparation. In the aftermath of an MCI, it is essential for medical personnel to accurately and promptly triage patients according to their acuity and urgency for care. As first responders bring patients from the field to the hospital, medical personnel are responsible for prompt secondary triage of these patients to appropriately delegate hospital resources. The JumpSTART triage algorithm (a variation of the Simple Triage and Rapid Treatment, or START, triage system) was originally designed for prehospital triage by prehospital providers but can also be used for secondary triage in the emergency department setting. This technical report describes a novel simulation-based curriculum for pediatric emergency medicine residents, fellows, and attendings involving the secondary triage of patients in the aftermath of an MCI in the emergency department. This curriculum highlights the importance of the JumpSTART triage algorithm and how to effectively implement it in the MCI setting.

Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage: A Report of Two Cases.

INTRODUCTION: Tranexamic acid (TXA) use in pediatrics to control hemorrhage has gained interest in recent years, but there is limited literature on nebulized TXA especially regarding dosing and adverse effects. Tranexamic acid has anti-fibrinolytic properties via competitive inhibition of plasminogen activation making it a logical approach to promote hemostasis in cases of post-tonsillectomy hemorrhage. CASE REPORT: We describe two cases of post-tonsillectomy hemorrhage managed with nebulized TXA. In both cases, bleeding was stopped after TXA administration. CONCLUSION: To our knowledge, this is the first case report to describe the use of nebulized TXA without an adjunct pharmacotherapy. Our two cases add additional reportable data on the safety of nebulized TXA and possible effectiveness on post-tonsillectomy hemorrhage.

Controversies in the management of neonatal testicular torsion: A meta-analysis.

OBJECTIVE: This meta-analysis seeks to discern the optimal management strategy in neonatal testicular torsion (NTT). METHODS: Reviewed all English-language articles published between 2005 and 2015 in Medline/Pubmed that had a defined diagnosis of NTT within the first thirty days of life, and discussed specific surgical and nonsurgical management. Exclusion criteria were non-English literature, case reports, case studies, and failure to clearly describe the management of NTT. Data from 9 studies were analyzed, individually and together as pooled data, using a random effect model with a random intercept to estimate the pooled proportions of interest. Results are presented with 95% confidence interval. All analyses were done in SAS 9.4®. RESULTS: 9 publications met criteria for this analysis with a total of 196 patients. Bilateral testicular torsions (n = 14) were less common as compared to right/left testicular torsion (n = 85/97). Asynchronous NTTs (n = 9) were more common than synchronous NTTs (n = 2). There was a higher incidence of NTT in neonates delivered by vaginal delivery (n = 110) as compared to those delivered by c-section (n = 25). Extravaginal torsion (n = 54) is far more common than intravaginal torsion (n = 2). Full-term neonates (n = 122) have a higher incidence of NTT as compared to preterm neonates (n = 9). A total of 15 testicles were salvaged. Of the salvaged testicles 2 were documented as prenatal, 10 postnatal and 3 were undocumented. A strategy of bilateral exploration allows for salvage of about 7% of ipsilateral testicles and prevent asynchronous torsion in about 4% of neonates. CONCLUSIONS: Based on our population, between 8-12% of patients would benefit from bilateral exploration at the time of diagnosis. We recommend urgent bilateral exploration with orchiopexy of the contralateral testicle in order to avert anorchia. TYPE OF STUDY: Systematic review. LEVEL OF EVIDENCE: Level 5 meta-synthesis (Evidence from systematic reviews of qualitative and descriptive studies).

Musculoskeletal Injuries Associated With Hoverboard Use in Children.

Hoverboards burst onto the scene with wide popularity only to be quickly deemed unsafe and banned in many arenas. We conducted a retrospective cohort study of 35 patients seen in our outpatient pediatric orthopedic office over a 1-year period. The mean age of injured patients was 11.14 years; 18 patients were male (51.4%), and 17 were female (48.5%). The highest number of injuries occurred in children 10 to 14 years old who had 57.1% of the injuries. There were a total of 31 fractures in 27 patients. Most of the fractures were in the upper extremities (93.6 %). Also, 9 soft-tissue injuries were found in 8 patients; 88.9 % of injuries occurred in the upper extremities. Most of the injuries were secondary to a fall (94.3%). We found that the most common injury was upper-extremity fracture. We suggest restricting riding <16 years and encourage protective equipment, especially elbow and wrist guards.