Predicting Complicated Mild Traumatic Brain Injury in Adolescent Trauma to Enhance Clinical Decisions in Imaging.

BACKGROUND: The Pediatric Emergency Care Applied Research Network (PECARN) traumatic brain injury algorithm is used to identify children at low risk of clinically significant traumatic brain injuries to reduce computed tomography (CT) exposure. Adapting PECARN rules based on population-specific risk stratification has been suggested to improve diagnostic accuracy. OBJECTIVE: This study sought to identify center-specific patient variables, beyond PECARN rules, that may enhance the identification of patients requiring neuroimaging. METHODS: This single-center, retrospective cohort study was conducted from July 1, 2016, to July 1, 2020, in a Southwestern U.S. Level II pediatric trauma center. The inclusion criteria were adolescents (10-15 years), Glasgow Coma Scale (13-15), with a confirmed mechanical blow to the head. Patients without a head CT were excluded. Logistic regression was performed to identify additional complicated mild traumatic brain injury predictor variables beyond the PECARN. RESULTS: There were 136 patients studied; 21 (15%) presented with a complicated mild traumatic brain injury. Relative to motorcycle collision or all-terrain vehicle trauma (odds ratio [OR] 211.75, 95% confidence interval, CI [4.51, 9931.41], p < .001), an unspecified mechanism (OR 42.0, 95% CI [1.30, 1350.97], p = .03) and consult activation (OR 17.44, 95% CI [1.75, 173.31], p = .01) were significantly associated with complicated mild traumatic brain injury. CONCLUSIONS: We identified additional factors associated with complex mild traumatic brain injury, including motorcycle collision and all-terrain vehicle trauma, unspecified mechanism, and consult activation that are not in the PECARN imaging decision rule. Adding these variables may aid in determining the need for appropriate CT scanning.

Assessing physician-parent communication during emergency medical procedures in children: an observational study in a low-literacy Latino patient population.

OBJECTIVE: Effective physician-patient communication is critical to the clinical decision-making process. We studied parental recall of information provided during an informed consent discussion process before performance of emergency medical procedures in a pediatric emergency department of an inner-city hospital with a large bilingual population. METHODS: Fifty-five parent/child dyads undergoing emergency medical procedures were surveyed prospectively in English/Spanish postprocedure for recall of informed consent information. Exact logistic regression was used to predict the ability to name a risk, benefit, and alternative to the procedure based on a parent's language, education, and acculturation. RESULTS: Among English-speaking parents, there tended to be higher proportions that could name a risk, benefit, or alternative. Our regression models showed overall that the parents with more than a high school education tended to have nearly 5 times higher odds of being able to name a risk. CONCLUSIONS: A gap in communication may exist between physicians and patients (or parents of patients) during the consent-taking process, and this gap may be impacted by socio-demographic factors such as language and education level.

Predictors of serious bacterial infections in pediatric burn patients with fever.

To determine predictors of serious bacterial infections in pediatric burn patients with fever (core temp ≥38.5°C), the authors conducted a retrospective review of medical records of pediatric (0-18 years) patients admitted to the Arizona Burn Center between 2008 and 2011 with greater than 5% TBSA and inpatient hospitalization for ≥72 hours. The study group comprised patients with a febrile episode during their inpatient stay. Serious bacterial infection (the primary outcome variable) was defined as: bacteremia, urinary tract infection, meningitis (blood, urine, or cerebrospinal fluid culture positive for a pathogen respectively), pneumonia, line, and wound infection. A generalized estimating equation analysis was done to predict the presence or absence of serious bacterial infection. Of 1082 pediatric burn patients hospitalized during the study period, 353 met the study eligibility criteria. A total of 108 patients (30.6%) had at least one fever episode (fever group). No difference in demographic characteristics was noted between the fever and no-fever groups; significant differences were observed for: third-degree TBSA, second-degree TBSA, total operating room visits, length of stay, Injury Severity Score, and death. A total of 47.2% of the patients had one or more episodes of fever with serious bacterial infection. In a generalized estimating equation predictive model, presence of a central line, second-, and third-degree TBSA were predictive of serious bacterial infection in burn patients with fever. In this study, individual clinical variables such as tachypnea and tachycardia were not predictive of serious bacterial infections, but the presence of a central line, and larger TBSA were significant predictors of serious bacterial infections. Younger age (P =.08) and ventilator support (P =.057) also approached significance as predictors of serious bacterial infections.

Antibiotic dosing for acute otitis media in children: a weighty issue.

BACKGROUND: The American Academy of Pediatrics 2004 guidelines on diagnosis and management of acute otitis media (OM) recommends use of high-dose amoxicillin for the treatment of acute uncomplicated OM. With rising childhood obesity, recommended amoxicillin dose of 80 to 90 mg/kg per day often exceed standard adult dose of 1500 mg/d. OBJECTIVE: To study prescribing patterns of primary care physicians for amoxicillin in the treatment of OM. To assess opinions of American Academy of Pediatrics subcommittee members who participated in guideline formulation. METHODS: This study had 2 parts. Part 1: Retrospective review of medical records of children visiting the hospital between April and June 2008 and with a diagnosis of OM and were prescribed amoxicillin. Part 2: Web-based survey of 14 members of the OM guidelines subcommittee. RESULTS: Part 1: Three hundred fifty-nine children were eligible, with a mean (SD) age of 3.2 (4.0) years and 185 (51.5%) of whom were males. Children weighing 20 kg or less received higher mean daily dose of amoxicillin (74.2 vs 40.4 mg/kg per day, P < 0.00). Part 2: Nine (64.3%) subcommittee members responded to the survey. Most (77.8%) affirmed that the impact of obesity on high-dose amoxicillin recommendation was not discussed during guideline formulation. If a patient's estimated amoxicillin dose exceeded the standard adult dose (1500 mg/d), 66.7% members would prescribe the standard adult dose whereas 33.3% would prescribe the recommended dose of 80 to 90 mg/kg per day. CONCLUSIONS: Primary care physicians prescribe a significantly lower-than-recommended amoxicillin dose in older children and those in the higher weight category. The opinion among subcommittee members regarding maximum dose specification of amoxicillin is varied.

Guidelines and levels of care for pediatric intensive care units.

The practice of pediatric critical care medicine has matured dramatically during the past decade. These guidelines are presented to update the existing guidelines published in 1993. Pediatric critical care services are provided in level I and level II units. Within these guidelines, the scope of pediatric critical care services is discussed, including organizational and administrative structure, hospital facilities and services, personnel, drugs and equipment, quality monitoring, and training and continuing education.

Guidelines and levels of care for pediatric intensive care units.

The practice of pediatric critical care medicine has matured dramatically during the past decade. These guidelines are presented to update the existing guidelines published in 1993. Pediatric critical care services are provided in level I and level II units. Within these guidelines, the scope of pediatric critical care services is discussed, including organizational and administrative structure, hospital facilities and services, personnel, drugs and equipment, quality monitoring, and training and continuing education.