Pediatric head injury: a pain for the emergency physician?
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ABSTRACT:
SUBMITTER: Chong SL
PROVIDER: S-EPMC5052852 | biostudies-other | 2015 Mar
REPOSITORIES: biostudies-other
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Pediatric head injury: a pain for the emergency physician?
Chong Shu-Ling SL Lee Khai Pin KP Lee Jan Hau JH Ong Gene Yong-Kwang GY Ong Marcus Eng Hock ME
Clinical and experimental emergency medicine 20150331 1
The prompt diagnosis and initial management of pediatric traumatic brain injury poses many challenges to the emergency department (ED) physician. In this review, we aim to appraise the literature on specific management issues faced in the ED, specifically: indications for neuroimaging, choice of sedatives, applicability of hyperventilation, utility of hyperosmolar agents, prophylactic anti-epileptics, and effect of hypothermia in traumatic brain injury. A comprehensive literature search of PubMe ...[more]
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Project description:BACKGROUND:Although head trauma-related deaths, hospitalizations, and emergency department visits are well characterized, few studies describe pediatric patients presenting outside of emergency departments. We compared the epidemiology and extent of healthcare-seeking pediatric (0-17 years) patients presenting in outpatient settings with those of patients seeking nonhospitalized emergency department care. METHODS:We used MarketScan Medicaid and commercial claims, 2004-2013, to identify patients managed in two outpatient settings (physician's offices/clinics, urgent care) and the emergency department. We then examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention-defined head trauma diagnoses, the extent of and reasons for post-index visit ambulatory care use within 30/90/180 days, and annual and monthly variations in head trauma trends. Outpatient incidence rates in 2013 provided estimates of the nationwide US outpatient burden. RESULTS:A total of 1,683,097 index visits were included, representing a nationwide burden in 2013 of 844,660 outpatient cases, a number that encompassed 51% of healthcare-seeking head trauma that year and that substantially increased in magnitude from 2004 to 2013. Two-thirds (68%) were managed in outpatient settings. While demographic distributions varied with index-visit location, injury-specific factors were comparable. Seasonal spikes appeared to coincide with school sports. CONCLUSIONS:There is an urgent need to better understand the natural history of head trauma in the >800,000 pediatric patients presenting each year for outpatient care. These outpatient injuries, which are more than double the number of head trauma cases recorded in the hospital-affiliated settings, illustrate the potential importance of expanding inclusion criteria in surveillance and prevention efforts designed to address this critical issue.
| S-EPMC5937022 | biostudies-literature
Project description:ImportanceGiven the mortality disparities among children and adolescents in rural vs urban areas, the unique health care needs of pediatric patients, and the annual emergency department volume for this patient population, understanding the availability of pediatric emergency physicians (EPs) is important. Information regarding the available pediatric EP workforce is limited, however.ObjectiveTo describe the demographic characteristics, training, board certification, and geographic distribution of the 2020 clinically active pediatric EP workforce in the US.Design, setting, and participantsThis national cross-sectional study of the 2020 pediatric EP workforce used the American Medical Association Physician Masterfile database, which was linked to American Board of Medical Specialties board certification information. Self-reported training data in the database were analyzed to identify clinically active physicians who self-reported pediatric emergency medicine (EM) as their primary or secondary specialty. The Physician Masterfile data were obtained on March 11, 2020.Main outcomes and measuresThe Physician Masterfile was used to identify all clinically active pediatric EPs in the US. The definition of EM training was completion of an EM program (inclusive of both an EM residency and/or a pediatric EM fellowship) or a combined EM program (internal medicine and EM, family medicine and EM, or pediatrics and EM). Physician location was linked and classified by county-level Urban Influence Codes. Pediatric EP density was calculated and mapped using US Census Bureau population estimates.ResultsA total of 2403 clinically active pediatric EPs were working in 2020 (5% of all clinically active emergency physicians), of whom 1357 were women (56%) and the median (interquartile range) age was 46 (40-55) years. The overall pediatric EP population included 1718 physicians (71%) with EM training and 641 (27%) with pediatric training. Overall, 1639 (68%) were board certified in pediatric EM, of whom 1219 (74%) reported EM training and 400 (24%) reported pediatrics training. Nearly all pediatric EPs worked in urban areas (2369 of 2402 [99%]), and pediatric EPs in urban compared with rural areas were younger (median [interquartile range] age, 46 [40-55] years vs 59 [48-65] years). Pediatric EPs who completed their training 20 years ago or more compared with those who completed training more recently were less likely to work in urban settings (633 [97%] vs 0-4 years: 440 [99%], 5-9 years: 547 [99%], or 10-19 years: 723 [99%]; P = .006). Three states had 0 pediatric EPs (Montana, South Dakota, and Wyoming), and 3 states had pediatric EPs in only 1 county (Alaska, New Mexico, and North Dakota). Less than 1% of counties had 4 or more pediatric EPs per 100 000 population.Conclusions and relevanceThis study found that almost all pediatric EPs worked in urban areas, leaving rural areas of the US with limited availability of pediatric emergency care. This finding may have profound implications for children and adolescents needing emergency care.
| S-EPMC8132138 | biostudies-literature
Project description:IntroductionElectrical injuries are rare but potentially life-threatening medical emergencies that require providers to manage a critically ill patient while recognizing and treating the unique sequelae associated with the diagnosis. This simulation case is designed to give pediatric and emergency medicine residents, fellows, attendings, and nurses the opportunity to practice these skills in a realistic setting.MethodsThis simulation-based curriculum was designed for a high-fidelity mannequin in an emergency department resuscitation room but can be adapted to fit a variety of learning environments. The case featured a 16-year-old boy presenting to the emergency department after arresting in the field after sustaining an electrical injury. He developed ventricular tachycardia during the simulation and had significant hyperkalemia, requiring emergent management. The included debriefing tools assisted instructors in providing formative feedback to learners.ResultsA total of 40 residents, medical students, and fellows participated in this scenario and provided overwhelmingly positive feedback about the learning experience. Mean Likert scores for participant confidence related to learning objectives after the simulation were 4 or greater on a 5-point scale.DiscussionThis case was developed to help learners at various levels of training recognize and manage a low-frequency, high-acuity scenario in a standardized environment. Participants specifically had the opportunity to perform airway management, cardiopulmonary resuscitation, defibrillation, and management of hyperkalemia, which may present in real life from a multitude of etiologies. The included materials helped prepare and assist facilitators with debriefing, supplemental education, and bidirectional feedback.
| S-EPMC6342442 | biostudies-literature
Project description:BackgroundAssess current and future pediatric emergency physician supply and need at 26 pediatric emergency departments (EDs) in 10 administrative regions across Saudi Arabia from 2021 through 2030.MethodsFor 10 administrative regions across Saudi Arabia, data were obtained on the size of the pediatric population (children <14 years old), the expected number of pediatric ED visits, and the number of pediatric emergency, fellowship-trained consultant physicians for the years 2015 through 2019. Time series linear regression modeling was used to estimate annual pediatric population sizes and pediatric ED visits for 2021-2030, based on 2015-2019 data trends. The projected number of pediatric emergency consultant physicians needed for 2021-2030 based on these trends was calculated according to a consensus method adopted by the Saudi Ministry of Health.ResultsFor the 10 Saudi Arabian administrative regions, the pediatric population is estimated to be 8,061,409 (95% confidence interval [CI]: 7,815,767 to 8,307,052) in 2021 and 9,764,591 (95% CI: 9,046,490 to 10,500,000) for 2030, and estimated the number of pediatric ED visits is 3,442,259 (95% CI: 3,013,697 to 3,870,822) for 2021 and 4,610,072 (95% CI: 3,026,986 to 6,193,158) for 2030. The projected number of pediatric emergency consultant physicians needed for 2021 is 1158 (95% CI: 1,002 to 1,314) and for 2030 is 1500 (95% CI: 985 to 2016), whereas deficit in number of pediatric emergency consultant physicians available is 1107 (95% CI: 944 to 1,270) for 2021 and 1405 (95% CI: 869 to 1,941) for 2030.ConclusionsThe study projections demonstrate a disparity between current and projected supply and demand of pediatric emergency physicians within Saudi Arabia.
| S-EPMC8769067 | biostudies-literature
Project description:ObjectivesMild traumatic brain injury (mTBI) is the most common emergency department (ED) brain injury presentation worldwide. Despite its frequency, practice variation and care gaps exist among emergency physicians (EPs) in diagnosing and appropriately managing mTBI in the ED. The objective of this review was to identify mTBI-specific training undertaken to improve the detection and management of mTBIs by EPs and its impact on practice.MethodsA comprehensive search strategy utilized four bibliographic databases, the gray literature and the keywords concussion, mild traumatic brain injury, medical education, and continuing medical education (CME). To be included, studies were required to report on mTBI training received by practicing EPs at any point during their medical education or career. Studies examining clinical practice guidelines or use of diagnostic tools without active implementation or formal training were not included. Two reviewers screened unique citations for relevance and reviewed the full texts of relevant articles. Two independent researchers extracted data and assessed methodologic quality. At all stages, a third independent reviewer adjudicated discrepancies.ResultsOverall, five studies were included from 409 unique results. None of the included studies were of high quality. Identified training on mTBI consisted of three training toolkits, conference presentations and academic journal articles, and pediatric fellowship training. Training primarily occurred as CME and focused on awareness of and management of mTBI; three studies reported physician practice changes, including increases in the use of evidence-based return-to-school and return-to-activity recommendations.ConclusionsThe few studies identified addressing mTBI training targeting EPs demonstrate the limited attention given to this issue. The current evidence-to-practice gap in mTBI management places patients at risk for suboptimal care in the ED, and existing mTBI knowledge translation, including education, requires optimization to effectively address the current gap in evidence-based practice for mTBI diagnosis and management in the ED.
| S-EPMC6001600 | biostudies-literature
Project description:IntroductionFirearm injury and death is increasingly prevalent in the United States. Emergency physicians (EP) may have a unique role in firearm injury prevention. The aim of this study was to describe EPs' beliefs, attitudes, practices, and barriers to identifying risk of and counseling on firearm injury prevention with patients. A secondary aim was assessment of perceived personal vulnerability to firearm injury while working in the emergency department (ED).MethodsWe conducted a cross-sectional survey of a national convenience sample of EPs, using questions adapted from the American College of Surgeons' Committee on Trauma 2017 survey of surgeons. Descriptive statistics and chi-square tests were calculated as appropriate.ResultsA total of 1901 surveys were completed by EPs from across the United States. Among respondents, 42.9% had a firearm at home, and 56.0% had received firearm safety training. Although 51.4% of physicians in our sample were comfortable discussing firearm access with their high-risk patients, more than 70% agreed or strongly agreed that they wanted training on procedures to follow when they identify that a patient is at high risk of firearm injury. Respondents reported a variety of current practices regarding screening, counseling, and resource use for patients at high risk of firearm injury; the highest awareness and self-reported screening and counseling on firearm safety was with patients with suicidal ideation. Although 92.3% of EPs reported concerns about personal safety associated with firearms in the ED, 48.1% reported that there was either no protocol for dealing with a firearm in the ED, or if there was a protocol, they were not aware of it. Differences in demographics, knowledge, attitudes, and behavior were observed between respondents with a firearm in the home, and those without a firearm in the home.ConclusionsAmong respondents to this national survey of a convenience sample of EPs, approximately 40% had a firearm at home. The majority reported wanting increased education and training to identify and counsel ED patients at high risk for firearm injury. Improved guidance on personal safety regarding firearms in the ED is also needed.
| S-EPMC7972360 | biostudies-literature
Project description:BackgroundWide variation exists for hospital admission rates for the evaluation of possible acute coronary syndrome, but there are limited data on physician-level variation. Our aim is to describe physicians' rates of admission for suspected acute coronary syndrome and associated 30-day major adverse events.MethodsWe conducted a retrospective analysis of adult emergency department chest pain encounters from January 2016 to December 2017 across 15 community emergency departments within an integrated health system in Southern California. The unit of analysis was the Emergency physician. The primary outcome was the proportion of patients admitted/observed in the hospital. Secondary analysis described the 30-day incidence of death or acute myocardial infarction.ResultsThirty-eight thousand seven hundred seventy-eight patients encounters were included among 327 managing physicians. The median number of encounters per physician was 123 (interquartile range, 82-157) with an overall admission/observation rate of 14.0%. Wide variation in individual physician admission rates were observed (unadjusted, 1.5%-68.9%) and persisted after case-mix adjustments (adjusted, 5.5%-27.8%). More clinical experience was associated with a higher likelihood of hospital care. There was no difference in 30-day death or acute myocardial infarction between high- and low-admitting physician quartiles (unadjusted, 1.70% versus 0.82% and adjusted, 1.33% versus 1.29%).ConclusionsWide variation persists in physician-level admission rates for emergency department chest pain evaluation, even in a well-integrated health system. There was no associated benefit in 30-day death or acute myocardial infarction for patients evaluated by high-admitting physicians. This suggests an additional opportunity to investigate the safe reduction of physician-level variation in the use of hospital care.
| S-EPMC7855368 | biostudies-literature
Project description:BackgroundInjuries are the leading cause of death in children and are also a leading cause of all emergency department (ED) visits for children. Obtaining epidemiologic data to define the wide range of childhood injuries for individual communities is challenging. The Children's Injury Database (CID) is an injury surveillance system developed to collect data from injury-related visits to our tertiary care pediatric emergency department.ResultsDuring 2021, a total of 15,168 injury visits were analyzed representing 22% of total ED visits (68,834). A total of 2053 injury visits (13.5%) resulted in hospital admission. The 10 leading injury types included: falls, poisonings, motor vehicle collision (MVC), assault, dog bite, burns, sports, pedestrian, bicycle, and all-terrain vehicle (ATV). Admission rates varied by age group with children ages 13 years and older having the highest rate of admission (18.4%). The median length of stay (LOS) for all injured children requiring admission was 2 days while the median LOS for preschoolers was 1 day, the median LOS for school-age children was 2 days, and the median LOS for teenagers was 3 days. While MVCs were the most common cause of vehicle-related injuries, ATV-related injuries had the highest rate of admission (51%).ConclusionsIn this study, teenagers had significantly higher admission rates, lengths of stay, and hospital charges. Black and Hispanic children were under-represented in the number of visits for injuries compared to all ED visits. Further research should focus on disparities in injury-related visits based on race as well as gender. CID has demonstrated that injury surveillance systems can assist with reporting new injury patterns while also acting as a stimulus for new research ideas, planning interventions targeting the most at-risk populations, and evaluating the effectiveness of injury prevention interventions.
| S-EPMC10391750 | biostudies-literature
Project description:BACKGROUND:In the treatment of pediatric traumatic brain injury (TBI), timely treatment of patients can affect the outcome. Our objectives were to examine the treatment process of acute pediatric TBI and the impact of non-value-added time (NVAT) on patient outcomes. METHODS:Data for 136 pediatric trauma patients (age < 18 years) with severe TBI from 2 trauma centers in the United States were collected. A process flow and value stream map identified NVATs and their sources in the treatment process. Cluster and regression analysis were used to examine the relationship between NVAT, as a percentage of the patient's length of stay (LOS), and the patient outcome, measured by their corresponding Glasgow outcome scale. RESULTS:There were 14 distinct sources of NVAT identified. A regression analysis showed that increased NVAT was associated with less favorable outcomes (relative ratio = 1.015, confidence interval = [1.002-1.029]). Specifically, 1% increase in the NVAT-to-LOS ratio was associated with a 1.5% increase in the chance of a less favorable outcome (i.e., death or vegetative state). CONCLUSION:The NVAT has a significant impact on the outcome of pediatric TBI, and every minute spent on performing non-value-added processes can lead to an increase in the likelihood of less favorable outcomes.
| S-EPMC5540834 | biostudies-literature
Project description:ImportanceThere is a lack of literature describing the incidence of pediatric acute ocular injury and associated likelihood of vision loss in the United States. Understanding national pediatric eye injury trends may inform future efforts to prevent ocular trauma.ObjectiveTo characterize pediatric acute ocular injury in the United States using data from a stratified, national sample of emergency department (ED) visits.Design, setting, and participantsA retrospective cohort study was conducted. Study participants received care at EDs included in the 2006 to 2014 Nationwide Emergency Department Sample, comprising 376 040 children aged 0 to 17 years with acute traumatic ocular injuries. Data were analyzed from June 2016 to March 2018.ExposuresInternational Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes and external-cause-of-injury codes identified children with acute ocular injuries.Main outcomes and measuresDemographic and clinical characteristics of children with acute traumatic ocular injuries were collected and temporal trends in the incidence of ocular injuries by age, risk of vision loss, and mechanism of injury were explored.ResultsIn 2014, there were an estimated 163 431 (95% CI, 151 235-175 627) ED visits for pediatric acute ocular injury. Injured children were more often male (63.0%; 95% CI, 62.5-63.5) and in the youngest age category (birth to 4 years, 35.3%; 95% CI, 34.4-36.2; vs 10-14 years, 20.6%; 95% CI, 20.1-21.1). Injuries commonly resulted from a strike to the eye (22.5%; 95% CI, 21.3-23.8) and affected the adnexa (43.7%; 95% CI, 42.7-44.8). Most injuries had a low risk for vision loss (84.2%; 95% CI, 83.5-85.0), with only 1.3% (95% CI, 1.1-1.5) of injuries being high risk. Between 2006 and 2014, pediatric acute ocular injuries decreased by 26.1% (95% CI, -27.0 to -25.0). This decline existed across all patient demographic characteristics, injury patterns, and vision loss categories and for most mechanisms of injury. There were increases during the study in injuries related to sports (12.8%; 95% CI, 5.4-20.2) and household/domestic activities (20.7%; 95% CI, 16.2-25.2). The greatest decrease in high-risk injuries occurred with motor vehicle crashes (-79.8%; 95% CI, -85.8 to -74.9) and guns (-68.5%; 95% CI, -73.5 to -63.6).Conclusions and relevanceThis study demonstrated a decline in pediatric acute ocular injuries in the United States between 2006 and 2014. However, pediatric acute ocular injuries continue to be prevalent, and understanding these trends can help establish future prevention strategies.
| S-EPMC6142941 | biostudies-literature