Accuracy of Parental-Reported Tetanus Vaccination Status for Children With Lacerations.

OBJECTIVES: The aim of this study was to determine whether emergency department (ED) providers are able to accurately assess whether a child with a laceration needs tetanus prophylaxis. METHODS: We conducted an 8-month prospective cross-sectional study of children presenting with a laceration to a pediatric ED. We asked ED providers whether tetanus prophylaxis was necessary. An ED pharmacist accessed the Utah Statewide Immunization Information System (USIIS), and we assessed the accuracy of the ED provider's determination of necessary tetanus prophylaxis compared with USIIS records. RESULTS: Among 375 patients aged 5 months to 17 years, ED providers made an inaccurate assessment of necessary tetanus prophylaxis in 33 cases (8.8%; 95% confidence interval [CI], 6.3%-12.1%). Emergency department providers would have inappropriately administered tetanus prophylaxis in 5 cases (1.3%; 95% CI, 0.5%-3.2%) and would have missed the need for tetanus prophylaxis in 28 cases (7.5%; 95% CI, 5.2%-10.6%). Emergency department providers were more likely to provide an inaccurate recommendation in older children (8.3 vs 4.8 years; P < 0.001), in patients with a dirty wound (45.5% vs 11.7%; P < 0.001), and in children who had fewer than 3 vaccines recorded in the USIIS (54.5% vs 1.2%; P < 0.001). CONCLUSIONS: Emergency department providers may inaccurately assess the need for tetanus prophylaxis in children. Special attention should be paid to cases of dirty wounds and cases in which fewer than 3 tetanus-containing vaccines have been given.

A Randomized Controlled Trial of Positioning for Lumbar Puncture in Young Infants.

OBJECTIVE: The lateral and sitting positions are those most widely used to perform lumbar puncture (LP) in infants. This study sought to compare LP success rates by position. Secondary outcomes were successful LP on the first attempt and rates of procedural complications. METHODS: Infants aged 1 to 90 days undergoing LP in our pediatric emergency department between June 1, 2012 and October 31, 2013 were randomized to 1 position or the other. Successful LP was defined as collection of cerebrospinal fluid with a red blood cell count of less than 10,000 cells/mm on either of the first 2 attempts. Electronic medical records were reviewed for patient information, cerebrospinal fluid results, and procedural complications. Providers completed a questionnaire detailing their previous LP experience and technique. Primary results were analyzed using the intention-to-treat principle. RESULTS: We enrolled 168 infants. Of 167 with data eligible for analysis, 82 (49%) were randomized to the lateral position. There was no statistically significant difference in LP success rate between the lateral (77%, 63/82) and sitting (72%, 61/85) positions (difference, 5.1%; 95% confidence interval, -8.2%-18.3%). There were no significant differences in success on the first LP attempt or the rates of procedural complications. CONCLUSIONS: Among infants 1 to 90 days of age, this study found no difference in LP success between the lateral and sitting positions.

Analysis of infant lumbar puncture success rates: sitting flexed versus lateral flexed positions.

OBJECTIVES: The primary objective was to determine whether the sitting flexed position yields higher success rates of obtaining cerebrospinal fluid (CSF) for culture. The secondary objectives were to determine whether the sitting flexed position yields higher success rates of obtaining the following: CSF for cell count, non-traumatic CSF, and CSF on the first attempt. METHODS: The study investigator performed a retrospective chart review of infants 0 to 365 days of age who had a lumbar puncture (LP) performed from January 1 to December 31 of 2010. Data on the LP position and the number of attempts were abstracted from procedure notes. Twenty-one LPs were excluded because of incomplete data on LP position and/or number of attempts. Spinal fluid count results were obtained from electronic medical records. Non-traumatic LPs were defined in 2 categories: CSF red blood cell counts of 500 cells per cubic millimeter or less and 10,000 cells per cubic millimeter or less. RESULTS: One hundred thirty-two LPs were included: 30 sitting flexed and 102 lateral flexed. There were no differences in success rates between positions for the primary objective of obtaining CSF for culture and the secondary study objectives of obtaining CSF for cell count and non-traumatic CSF. A significant secondary objective was that operators who performed the LP in the sitting flexed position were more likely to obtain CSF on the first attempt (odds ratio, 2.74; confidence interval, 1.17-6.45). CONCLUSIONS: The sitting flexed position was as successful as the lateral flexed position in the primary objective of obtaining CSF for culture and the secondary objectives of obtaining CSF for cell count and non-traumatic CSF. For the secondary objective of obtaining CSF on the first attempt, the sitting flexed position was associated with a higher rate of obtaining CSF on the first attempt in infants younger than 12 months.

Characteristics of the pediatric patients treated by the Pediatric Emergency Care Applied Research Network's affiliated EMS agencies.

OBJECTIVE: To describe pediatric patients transported by the Pediatric Emergency Care Applied Research Network's (PECARN's) affiliated emergency medical service (EMS) agencies and the process of submitting and aggregating data from diverse agencies. METHODS: We conducted a retrospective analysis of electronic patient care data from PECARN's partner EMS agencies. Data were collected on all EMS runs for patients less than 19 years old treated between 2004 and 2006. We conducted analyses only for variables with usable data submitted by a majority of participating agencies. The investigators aggregated data between study sites by recoding it into categories and then summarized it using descriptive statistics. RESULTS: Sixteen EMS agencies agreed to participate. Fourteen agencies (88%) across 11 states were able to submit patient data. Two of these agencies were helicopter agencies (HEMS). Mean time to data submission was 378 days (SD 175). For the 12 ground EMS agencies that submitted data, there were 514,880 transports, with a mean patient age of 9.6 years (SD 6.4); 53% were male, and 48% were treated by advanced life support (ALS) providers. Twenty-two variables were aggregated and analyzed, but not all agencies were able to submit all analyzed variables and for most variables there were missing data. Based on the available data, median response time was 6 minutes (IQR: 4-9), scene time 15 minutes (IQR: 11-21), and transport time 9 minutes (IQR: 6-13). The most common chief complaints were traumatic injury (28%), general illness (10%), and respiratory distress (9%). Vascular access was obtained for 14% of patients, 3% received asthma medication, <1% pain medication, <1% assisted ventilation, <1% seizure medication, <1% an advanced airway, and <1% CPR. Respiratory rate, pulse, systolic blood pressure, and GCS were categorized by age and the majority of children were in the normal range except for systolic blood pressure in those under one year old. CONCLUSIONS: Despite advances in data definitions and increased use of electronic databases nationally, data aggregation across EMS agencies was challenging, in part due to variable data collection methods and missing data. In our sample, only a small proportion of pediatric EMS patients required prehospital medications or interventions.

Decreased pediatric hospital mortality after an intervention to improve emergency care in Lilongwe, Malawi.

BACKGROUND AND OBJECTIVE: Emergently ill infants and children are often inadequately recognized and stabilized by health care facilities in the developing world. This deficiency contributes to high inpatient mortality rates, particularly early during hospitalization. Our referral hospital in Lilongwe, Malawi, experiences high volume, acuity, and mortality rates. The entry point to our hospital for most children presenting with acute illness is the Under-5 Clinic. We hypothesized that early inpatient mortality and total inpatient mortality rates would decrease with an intervention to prioritize and improve pediatric emergency care at our hospital. METHODS: We implemented the following changes as part of our intervention: (1) reallocation of senior-level clinical support from other areas of the hospital to the Under-5 Clinic for supervision of emergency care, (2) institution of a formal triage process that improved patient flow, and (3) treatment and stabilization of patients before transfer to the inpatient ward. We compared early inpatient and total inpatient mortality rates before and after the intervention. RESULTS: After the intervention, early mortality decreased from 47.6 to 37.9 deaths per 1000 admissions (relative risk 0.80, 95% confidence interval 0.67-0.93). Total mortality also decreased from 80.5 to 70.5 deaths per 1000 admissions after the intervention (relative risk 0.88, 95% confidence interval 0.78-0.98). CONCLUSIONS: Simple, inexpensive interventions to improve pediatric emergency care at this underresourced hospital in sub-Saharan Africa were associated with decreased hospital mortality rates. The description of this process and the associated results may influence practice and resource allocation strategies in similar clinical environments.

Musculoskeletal injuries in the pediatric and adolescent athlete.

There are approximately 35 million children participating in organized sports in the United States. With this increasing participation, we have seen an overall increase in sports-related injuries in young athletes over the past 20 years. Young athletes suffer both acute and chronic, or overuse, injuries. They are susceptible to many of the same injuries as their adult counterparts, but due to the effects of growth on the musculoskeletal system, they are at risk for injuries to the growth plate, apophysis, and joint surface. Common acute and overuse injuries seen in young athletes are discussed here.