Decreased Mortality After Establishing a Pediatric Emergency Unit at an Urban Referral Hospital in Ghana.

ABSTRACT: Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in low- and middle-income countries. Limited reports have shown that process improvements and prioritization of emergency care for children presenting to the hospital can improve pediatric hospital mortality.A dedicated pediatric emergency unit (PEU) was established for nontrauma emergencies at a busy teaching and referral hospital in Kumasi, Ghana, in response to high inpatient mortality early during hospitalization. The PEU was designed to identify and separate critically ill children from more stable children on admission. Locally available hospital resources were reallocated from other areas of the hospital to prioritize staffing and supplies for the PEU.A multiyear data set of nonnewborn inpatient mortality was analyzed with a change point model to find the point at which mortality changed the most within the Department of Child Health or the maximum likelihood estimate. Relative risk of mortality for the periods 1 and 2 years immediately before and after the implementation of the PEU and each individual year compared with its preceding year was analyzed to further establish a temporal correlation of changes in mortality rates to the PEU implementation. Individual years were also analyzed against preimplementation data to establish the durability of mortality improvements.Patient mortality decreased over the analyzed period with the maximum change point strongly associated with implementation of the PEU. Relative risk values of mortality 1 year and 2 years immediately before and after implementation of the PEU were 0.70 (0.62-0.78) and 0.69 (0.64-0.74) respectively, representing a one-third reduction in mortality. The only other mortality improvements seen in the year-to-year analysis were between July 2004-June 2005 compared with July 2005-June 2006 with a relative risk of 0.86 (0.77-0.96).Prioritizing and redirecting limited resources toward pediatric emergency care in low- and middle-income country hospitals is associated with reductions in inpatient mortality that are both immediate and sustained.

Chair Lift Falls and Injuries in Children.

OBJECTIVE: The objective of this study was to compare demographic injury and treatment characteristics of hospitalized pediatric cases of falls from chair lifts to cases of other ski and snowboarding injuries and identify potential interventions for preventing falls from chair lifts. METHODS: Retrospective query of the trauma registry of Utah's only pediatric trauma center for children younger than 18 years requiring hospitalization for a ski or snowboarding injury from November 2004 to February 2014. RESULTS: There were 443 cases of hospitalized ski and snowboarding injuries during the study period. Twenty-nine cases (7%) fell from height while riding a chair lift. Children falling from chair lifts were more likely to be younger (6.9 years vs 12.1, P < 0.0001), female (41% vs 20%, P < 0.01), and elicit trauma team activation (72% vs 34%, P = <0.0001) but were less frequently treated in the operating room (14 vs 24%, P = 0.02) than children with other ski and snowboarding injuries. There were no differences in mortality, injury severity score, length of hospital stay, or airway intubation outside the operating room. When stated (11/29 cases), mean estimated height of fall from lift was 26 feet. The most common body region in chair lift falls with a significant injury (abbreviated injury scale, ≥3) was lower extremity (4/29, all femur fractures). Patient age discriminated chair lift falls well (area under the receiver operating characteristic curve, 0.87) with age of 7 years and below predicting chair lift fall with a sensitivity of 76% and a specificity of 91%. CONCLUSIONS: Injuries requiring hospitalization after falls from chair lifts occur at regulated facilities and are more common in younger female children when compared with other ski and snowboarding injuries. Interventions for reducing falls from chair lifts may be most effective applied to children 7 years and younger.

Seatbelt Syndrome in Children.

The seatbelt syndrome describes an injury pattern infrequently seen in restrained passengers in motor vehicle collisions. It occurs when sudden deceleration forces coupled with compression of the lap belt around the abdomen causes abdominal wall bruising, intra-abdominal injuries, and spinal fractures. Infrequent and improper use of appropriate belt restraints in children has led to high risks for injury in this population.We describe a case of the seatbelt syndrome with the uncommon finding of an associated posttraumatic intestinal obstruction. We also review the literature on the prevalence, risk factors, and types of injuries sustained by children with the seatbelt syndrome as well as discuss the indications for laboratory studies, abdominal imaging, surgical intervention, and further observation. Current recommendations for child seatbelt use and its effectiveness in preventing injury are also reviewed.

The role of ultrasound in the emergency department evaluation of the acutely painful pediatric hip.

Children presenting with hip pain or a limp are a diagnostic challenge for the clinician. The differential diagnosis is extensive, and the workup can be broad. This review focuses on differentiating between transient synovitis and septic arthritis of the hip. The role of bedside ultrasound in the clinical evaluation of these patients is addressed, including the technique and appropriate indications for bedside ultrasound of the hip in the emergency department.

Implementing an ultrasound-based protocol for diagnosing appendicitis while maintaining diagnostic accuracy.

BACKGROUND: The use of ultrasound to diagnose appendicitis in children is well-documented but not universally employed outside of pediatric academic centers, especially in the United States. Various obstacles make it difficult for institutions and radiologists to abandon a successful and accurate CT-based imaging protocol in favor of a US-based protocol. OBJECTIVE: To describe how we overcame barriers to implementing a US-based appendicitis protocol among a large group of nonacademic private-practice pediatric radiologists while maintaining diagnostic accuracy and decreasing medical costs. MATERIALS AND METHODS: A multidisciplinary team of physicians (pediatric surgery, pediatric emergency medicine and pediatric radiology) approved an imaging protocol using US as the primary modality to evaluate suspected appendicitis with CT for equivocal cases. The protocol addressed potential bias against US and accommodated for institutional limitations of radiologist and sonographer experience and availability. Radiologists coded US reports according to the probability of appendicitis. Radiology reports were compared with clinical outcomes to assess diagnostic accuracy. During the study period, physicians from each group were apprised of the interim US protocol accuracy results. Problematic cases were discussed openly. RESULTS: A total of 512 children were enrolled and underwent US for evaluation of appendicitis over a 30-month period. Diagnostic accuracy was comparable to published results for combined US/CT protocols. Comparing the first 12 months to the last 12 months of the study period, the proportion of children achieving an unequivocal US result increased from 30% (51/169) to 53% (149/282) and the proportion of children undergoing surgery based solely on US findings increased from 55% (23/42) to 84% (92/109). Overall, 63% (325/512) of patients in the protocol did not require a CT. Total patient costs were reduced by $30,182 annually. CONCLUSION: We overcame several barriers to implementing a US protocol. During the study period our ability to visualize the appendix with US increased and utilization of CT decreased. Our overall diagnostic accuracy with the US-based protocol was comparable to other published results and remained unchanged throughout the study.

What happens in stapled transanal rectum resection?

INTRODUCTION: Stapled transanal rectum resection is becoming increasingly popular as a surgical option for the treatment of obstructive defecation syndrome. However, details about the anatomical changes produced by stapled transanal rectum resection and its correlation with success or failure is poorly understood. The aim of this study was to correlate the defecographical and clinical patterns in patients treated with stapled transanal rectum resection. PATIENTS AND METHODS: Based on a multi-institutional stapled transanal rectum resection registry composed of a total of 182 patients, correlation analysis of clinical and radiological parameters was prospectively obtained from 51 patients with a completed 12-month follow-up. RESULTS: Postoperative defecography shows significant changes in the following parameters: intussusception (89%-19%; P < .0001), enterocele (38%-18%; P = .038), rectocele (mean ± SD: 27.1 ± 7.4 mm to 16.5 ± 9.7 mm; P < .0001), rectal lumen (mean ± SD: 46 ± 11.4 mm to 35 ± 9.9 mm; P < .0001), anorectal angle (mean ± SD: 146.4 ± 10.6° to 132.4 ± 11.1°; P = .002), pelvic floor descent (mean ± SD: 59 ± 18 mm to 47 ± 1.3 mm; P = .0001), and, as a dynamic parameter, dynamic pelvic floor descent (mean ± SD: 30 ± 0.8 mm to 17 ± 0.4 mm; P < .0001). Of these parameters, reduction of intussusception (r = 0.433, 95% CI 0.15-0.61; P = .003), rectocele (r = 0.507, 95% CI 0.26-0.67; P = .001), and dynamic pelvic floor descent (r = 0.427, 95% CI 0.31-0.64; P = .001) correlated with a significant improvement in constipation. Reduction of intussusception positively affected postoperative continence (r = 0.524, 95% CI 0.29-0.70; P = .001), whereas reduced rectal lumen size correlated with incontinence and fecal urgency (r = -0.557, 95% CI -0.69 to -0.28; P = .001). CONCLUSIONS: Improved constipation after stapled transanal rectum resection is associated with improvement of intussusception, rectocele, and dynamic pelvic floor descent. Postoperative continence is determined by 2 parameters, reduction of intussusception and rectal lumen size, which have opposing effects. Reduction of rectal lumen size may be responsible for new-onset fecal urgency, which is occasionally seen after stapled transanal rectum resection.

Amiodarone for the emergency care of children.

Amiodarone is a class 3 antiarrhythmic agent used for a broad range of arrhythmias including adenosine-resistant supraventricular tachycardia, junctional ectopic tachycardia, and ventricular tachycardia. Compared with adults, there are few data on its use in children with arrhythmias resistant to conventional therapy. National and international guidelines for cardiopulmonary resuscitation and emergency cardiovascular care recommend its use for a variety of arrhythmias based on case reports, cohort studies, and extrapolation from adult data. This article will review the historical development, chemical properties, metabolism, indications and contraindications, and adverse effects of amiodarone in infants and children. After completing this CME activity, the reader should be able to utilize amiodarone in the pediatric population for arrhythmias and identify complications associated with its use.

Infant carrier-related falls: an unrecognized danger.

OBJECTIVE: Our objective was to describe young children injured through the use of infant carrier car seats, comparing them with children injured through other fall mechanisms. METHODS: We performed a retrospective chart review of children 18 months or younger with a fall mechanism of injury presenting to the emergency department of a tertiary care level 1 pediatric trauma center from August 2004 to December 2005. The primary outcome measure of the study was to determine the pattern of injuries sustained by infants falling from infant carrier seats. RESULTS: Eight hundred three children were identified. There were 62 patients (7.7%) with infant carrier falls with a mean age of 4.4 months. Of these patients, 87.1% were not buckled into their carriers. Infant carrier-related falls resulted in 22 hospitalizations (35.5%), including 6 pediatric intensive care unit admissions (9.7%). Thirteen patients in the group with infant carrier-related falls sustained intracranial injuries (ICIs; subdural hematoma, 8; epidural hematoma, 3; cerebral contusion, 1; and subarachnoid hemorrhage, 1); 1 patient required a craniotomy. Ten patients had isolated skull fractures, and 11 of the 13 patients with ICIs also had skull fractures. The 62 carrier patients were compared with 741 children with other fall mechanisms. The carrier group had more ICIs (P < 0.001) and hospitalizations (P < 0.001). When carrier injuries were compared with falls down stairs, there were more ICIs (13/62 vs. 2/68, P = 0.002) resulting from carrier injuries. CONCLUSIONS: Falls from infant carriers are common, often involve children unbuckled in their car seats, and represent a significant source of morbidity. Injury prevention measures such as education and manufacture labeling may be effective strategies.

Alternative model for a pediatric trauma center: efficient use of physician manpower at a freestanding children's hospital.

BACKGROUND: Freestanding children's hospitals may lack resources, especially surgical manpower, to meet American College of Surgeons trauma center criteria, and may organize trauma care in alternative ways. MATERIALS AND METHODS: At a tertiary care children's hospital, attending trauma surgeons and anesthesiologists took out-of-hospital call and directed initial care for only the most severely injured patients, whereas pediatric emergency physicians directed care for patients with less severe injuries. Survival data were analyzed using TRISS methodology. RESULTS: A total of 903 trauma patients were seen by the system during the period 10/1/96-6/30/01. Median Injury Severity Score was 16, and 508 of patients had Injury Severity Score > or =15. There were 83 deaths, 21 unexpected survivors, and 13 unexpected deaths. TRISS analysis showed that z-score was 4.39 and W-statistic was 3.07. CONCLUSIONS: Mortality outcome from trauma in a pediatric hospital using this alternative approach to trauma care was significantly better than predicted by TRISS methodology.

Neurodevelopmental outcome for extended cold water drowning: a longitudinal case study.

There is little longitudinal data examining outcome of pediatric near-drowning. Most literature tracks status 5 years or less post insult, focusing primarily on gross neurologic status as opposed to more subtle neurocognitive deficits. The present case tracks the neuropsychological profile of a child who was submerged for 66 min, the longest time documented. Acute medical support was aggressive, and recovery was dramatic, being featured in multiple media reports. Although an article published 6 years after the near-drowning described the child as "recovering completely," the longitudinal profile indicates a pronounced pattern of broad cognitive difficulties, particularly notable for global memory impairment. Neuropsychological test results were significant despite the fact that the patient's recent MRI and MEG were within normal limits. This case demonstrates the need for long-term neuropsychological follow-up of pediatric patients with histories of neurologic injury, as gross neurological examination and MRI and MEG scans may not reveal underlying brain dysfunction.