Low Concordance Between Pediatric Emergency Attendings and Pediatric Residents for Predictors of Serious Intracranial Injury.

OBJECTIVES: Minor head trauma is a common cause of pediatric emergency room visits. The Pediatric Emergency Care Applied Research Network head trauma clinical decision rules (PECARN-CDR) are designed to assist clinicians in determining which patients require imaging. However, only minimal data are available on the accuracy of residents' assessments using PECARN-CDR. Prior research suggests that trainees often come to erroneous conclusions about pediatric head trauma. The objective of the present study was to assess concordance between pediatric residents' and attending physicians' assessments of children with low-risk head trauma, with the ultimate goal of improving education in pediatric trauma assessment. METHODS: This is a retrospective cohort study analyzing concordance between pediatric residents and pediatric emergency attendings who provided PECARN-CDR-based evaluations of low-risk head injuries. It is a planned subanalysis based on a prospectively collected, multicenter data set tracking pediatric head trauma encounters from July 2014 to June 2019. RESULTS: Data were collected from 436 pediatric residents, who encountered 878 patients. In the case of patients younger than 2 years, low concordance between residents and attendings was observed for the following elements of the PECARN-CDR: severe mechanism (κ = 0.24), palpable skull fracture (κ = 0.23), Glasgow Coma Scale (GCS) score less than 15 (κ = 0.14), and altered mental status (AMS; κ = -0.03). There was moderate to high agreement between residents and attendings for loss of consciousness (κ = 0.71), nonfrontal hematoma (κ = 0.48), and not acting normally per parent (κ = 0.35). In the case of patients older than 2 years, there was low concordance for signs of basilar skull fracture (κ = 0.28) and GCS score less than 15 (κ = 0.10). Concordance was high to moderate for history of vomiting (κ = 0.88), loss of consciousness (κ = 0.67), severe headache (κ = 0.50), severe mechanism (κ = 0.44), and AMS (κ = 0.42). Residents were more conservative, that is, more likely to report a positive finding, in nearly all components of the PECARN-CDR. CONCLUSIONS: Resident assessment of children presenting to the ED with minor head trauma is often poorly concordant with attending assessment on the major predictors of clinically important traumatic brain injury (abnormal GCS, AMS, signs of skull fracture) based on the PECARN-CDR. Future work may explore the reasons for low concordance and seek ways to improve pediatric resident education in the diagnosis and management of trauma.

Effectiveness of a Simulation Curriculum on Clinical Application: A Randomized Educational Trial.

INTRODUCTION: The use of simulation to develop clinical reasoning and medical decision-making skills for common events is poorly established. Validated head trauma rules help identify children at low risk for clinically important traumatic brain injury and guide the need for neuroimaging. We predicted that interns trained using a high-fidelity, immersive simulation would understand and apply these rules better than those trained using a case-based discussion. Our primary outcomes were to determine the effectiveness of a single targeted intervention on an intern's ability to learn and apply the rules. METHODS: This was a prospective randomized controlled trial. Interns were randomized to participate in either a manikin-based simulation or a case discussion. Knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool were assessed both under testing conditions using standardized vignettes and in clinical encounters. In both settings, interns completed a validated assessment tool to test their knowledge and application of the Pediatric Emergency Care Applied Research Network Head Trauma tool when assessing patients with head injury. RESULTS: Under testing conditions, both being in the simulation group and shorter time from training were independently associated with higher score under testing conditions using standardized vignettes (P = 0.038 and P < 0.001), but not with clinical encounters. CONCLUSIONS: Interns exposed to manikin-based simulation training demonstrated performance competencies that are better than those in the case discussion group under testing conditions using standardized vignettes, but not in real clinical encounters. This study suggests that information delivery and comprehension may be improved through a single targeted simulation-based education.

The pandemic of workplace violence: the gendered experience of emergency medicine trainees.

OBJECTIVES: Many health care providers experience physical and verbal abuse from patients and their visitors. This abuse is a form of workplace violence and likely has negative implications for the providers well-being. The objective of our study was to determine the rates of nonphysical workplace violence against emergency medicine (EM) trainees with a focus on prevalence by provider gender. METHODS: This was a single-center prospective cohort study using tally counters to track occurrences of nonphysical workplace violence perpetrated by patients and their visitors against EM trainees in the adult emergency department. RESULTS: There were a total of 39 completed responses submitted by 22 respondents. Of the 22 respondents, 14 identified as women and eight identified as men. On average, both men and women experienced near daily occurrences of nonphysical workplace violence. However, women experienced higher rates compared to their colleagues who are men with a mean of three occurrences per day versus 0.9, respectively. CONCLUSION: We found that women trainees were more likely to experience nonphysical workplace violence from patients and their visitors.

Brief Resolved Unexplained Event: Not Just a New Name for Apparent Life-Threatening Event.

OBJECTIVES: This study aimed to evaluate patients who presented to the pediatric emergency department with an apparent life-threatening event (ALTE) to (1) determine if these patients would meet the criteria for brief resolved unexplained event (BRUE), a new term coined by the American Academy of Pediatrics in May, 2016; (2) risk stratify these patients to determine if they meet the BRUE low-risk criteria; and (3) evaluate outcomes of patients meeting the criteria for BRUE. METHODS: We conducted a retrospective chart review of patients who presented to a large urban academic center pediatric emergency department with an ALTE from January 2013 to May 2015 (before the publication of the BRUE guideline). Children ≤12 months of age were identified by the International Classification of Diseases, Ninth/Tenth Revision. Two physician reviews were performed to determine if patients met the ALTE diagnostic criteria. Data were then extracted from these charts to complete objectives. RESULTS: Seventy-eight patients met the diagnostic criteria for ALTE. Only 1 of those patients met the diagnostic criteria for BRUE, but not for low-risk BRUE. This patient underwent an extensive inpatient evaluation and was eventually discharged after monitoring with a benign diagnosis. Most patients did not meet the criteria for BRUE because the event was not unexplained. CONCLUSIONS: Only 1 patient who presented to the ED with ALTE met the criteria for BRUE, and this patient did not meet the low-risk criteria. This study corroborates previous research on BRUE and continues to highlight the importance of conducting a thorough history and physical examination on all patients presenting to the ED with concerning events.

Acute Urinary Retention Caused by an Ovarian Teratoma-A Unique Pediatric Presentation and Review.

BACKGROUND: Acute urinary retention (AUR) is a rare diagnosis both in pediatric and adult female populations, especially when compared to adult males. AUR occurs in women at a rate of 7 in 100,000 per year in a 1:13 female to male ratio. Multiple studies have shown that within the pediatric population AUR is far less common in females and is caused by different pathologies than AUR in adult women. CASE REPORT: We report the case of an 11 year-old prepubescent female who presented to the emergency department with acute urinary retention found to be caused by a mature cystic ovarian teratoma. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Our case is unique in that it describes an ovarian mass leading to AUR which has not previously been described in the pediatric literature. We will review the causes of AUR in the pediatric female population and compare these to the causes of AUR in other populations.

Randomized trial comparing wound packing to no wound packing following incision and drainage of superficial skin abscesses in the pediatric emergency department.

OBJECTIVE: The objective of this study was to investigate the impact of wound packing versus no wound packing on short-term failure rates and long-term recurrences after incision and drainage (I&D) of a simple cutaneous abscess. METHODS: In this randomized, single-blind, prospective study, subjects between the ages 1 and 25 years with skin abscesses needing an I&D were enrolled consecutively and randomized to be packed or not packed following the procedure. Treatment failure was assessed at a 48-hour follow-up visit by a masked observer who rated the need for a major intervention (repeat I&D or re-exploration) or minor intervention (antibiotics initiated or changed, need for packing, or repeat visit). Pain scores were assessed using color analog scales before and after the procedure and repeated at the 48-hour follow-up visit. Healing and abscess recurrence were assessed via telephone interview at 1 week and 1 month. RESULTS: Fifty-seven subjects were enrolled over a 15-month period. Overall failure rates were similar between the groups, with 19 (70%) of 27 subjects in the packed group needing an intervention by 48 hours compared with 13 (59%) of 22 subjects in the nonpacked group who needed an intervention (difference, 11%; 95% confidence interval, -15% to 36%). Major and minor intervention rates were also similar. Pain scores did not significantly differ between groups. CONCLUSIONS: Wound packing does not appear to significantly impact the failure or recurrence rates after simple I&D. Larger studies are needed to better validate the equivalency of these 2 strategies.

A randomized, double-blind controlled study of jet lidocaine compared to jet placebo for pain relief in children undergoing needle insertion in the emergency department.

OBJECTIVES: The objectives were to determine whether pretreatment with needleless jet-delivered lidocaine decreases self-reported pain in children undergoing needle insertion in the emergency department (ED) and to explore whether pretreatment with a jet device decreases self-reported pain in children undergoing needle insertion in the ED. METHODS: This study examined needle insertion pain in children 5-18 years of age. In the first phase of this study, children received either pretreatment with jet-delivered lidocaine (0.2 mL of buffered 1% lidocaine; n = 75) or pretreatment with jet-delivered placebo (0.2 mL of preservative-free normal saline; n = 75) 60 seconds before undergoing needle insertion. This phase of the study had a randomized, double-blind, placebo-controlled design. In the second phase, an unblinded, nonconcurrent, nonintervention control group (n = 47) was examined to describe any effect of using the jet device. Patients reported pain upon administration of the jet device and at needle insertion using a 100-mm color analog scale (CAS). Patients also reported their satisfaction with this device. The physicians and nurses performing needle insertions were asked to rate their ability to visualize the vein and their satisfaction with the device. RESULTS: The mean (+/-standard deviation [SD]) needle insertion pain score for jet lidocaine, 28 (+/-7) mm, was similar to the mean needle insertion pain score for jet placebo, 34 (+/-7) mm. The mean needle insertion pain score for both the jet lidocaine and the jet placebo groups were lower than the needle insertion pain scores for the no device group, 52 (+/-8) mm. The majority of patients receiving the jet device reported that they would request this device for future needle insertions. Providers' ratings of their ability to visualize veins and the patient cooperation were similar in all three groups. CONCLUSIONS: Jet-delivered lidocaine is no more effective than jet-delivered placebo in providing local anesthesia for needle insertion. Jet lidocaine and jet placebo may provide superior analgesia compared to no local anesthetic pretreatment.

Children requiring psychiatric consultation in the pediatric emergency department: epidemiology, resource utilization, and complications.

METHODS: A cohort of children younger than 18 years presenting to an urban pediatric emergency department (PED) who underwent psychiatric consultation was analyzed. A standardized data collection sheet was prospectively completed and included: patient characteristics, extent of medical evaluation and findings, ancillary diagnostic studies, resources utilized, dangerous behaviors, and disposition. RESULTS: Two hundred ten patients required psychiatric evaluation. Median age was 14 years; 51.9% were boys; 71.9% had a past psychiatric history; 39.0% had prior psychiatric admission(s), and 40.5% were on psychiatric medications. The admission rate was 49.5%. Patients spent a median of 5.7 hours in the PED. Hospital police monitored 51.9% patients. Forty-five patients had 91 dangerous behaviors. Those patients presenting with a complaint of aggressive behavior (P = 0.00006), a past psychiatric history (P = 0.003), or a history of prior psychiatric hospitalization (P = 0.005) were more likely to have dangerous behaviors. Two hundred nine patients underwent a complete medical evaluation, and 207 were considered medically cleared. Patients who had diagnostic evaluations for medically indicated reasons were significantly more likely to have abnormal results than those requested by the psychiatric consultant for screening purposes (43.6% vs. 9.2%; relative risk, 2.33; 95% confidence interval, 1.33-4.08) but were not statistically more likely to result in medical intervention (5.4% vs. 0%, P = 0.243). CONCLUSIONS: PED patients requiring psychiatric consultation and psychiatric admission had a prolonged PED stay and a high incidence of dangerous behaviors requiring intervention. History and physical examination adequately identified medical illness. Laboratory evaluation obtained for psychiatric transfer or admission purposes was of low yield.