UMEM Educational Pearls - By Jennifer Guyther

Category: Pediatrics

Title: Does the height of fever matter in the era of vaccines?

Keywords: fever, temperature, infection (PubMed Search)

Posted: 6/21/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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Teaching has circulated that a temperature of 40 degrees Celsius or above (hyperpyrexia), was associated with a greater incidence of serious bacterial infection.  However, this teaching originated in a time prior to the availability of childhood vaccinations. In fact, the largest retrospective study to support this used data from 1966-1974.  

2565 WELL APPEARING patients between the ages of 61 days and their 18th birthday who presented to a single tertiary care pediatric emergency department with the chief complaint of fever were included.  The prevalence of serious bacterial infection was compared to the presence of hyperpyrexia, age, chronic conditions, gender and vaccination status.

Serious bacterial infections (SBIs) included: deep space infections, appendicitis, pneumonia, mastoiditis, lymphadenitis, acute bacterial rhinosinusitis, urinary tract infection, pyelonephritis, cholecystitis, tubo-ovarian abscess, septic arthritis, osteomyelitis, bacteremia or bacterial meningitis.

There was NO statistically significant association between hyperpyrexia and SBIs. Older age and make sex were associated with a higher risk of SBIs.

Bottom line: In well appearing children 61 days and older, having a temperature >/= to 40 degrees was not associated with serious bacterial infections.

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Category: EMS

Title: Is prehospital intubation harmful for patients who require a resuscitative thoracotomy?

Keywords: intubation, timing, trauma arrest, prehospital (PubMed Search)

Posted: 6/19/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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Several studies have shown that patients who require a resuscitative thoracotomy (RT)  have a higher odds of survival if they are transported by police or in private vehicles.  This study examined 195 patients who required RT to see if prehospital intubation and out of hospital time (OOHT) affected ROSC rates.

There was no association between OOHT and ROSC and no association of OOHT and survival.  The mean OOHT for this study was only 25 minutes which is faster than other studies.  

The odds of ROSC were lower in patients who had ANY intubation attempts prior to arrival.

Bottom line: BLS airway management (or supraglottic placement) may be more beneficial for the trauma arrest patient in the prehospital setting.

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Category: Pediatrics

Title: Seasonality of pediatric visits for suicidality

Keywords: psych, pediatric mental health, suicide (PubMed Search)

Posted: 5/17/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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This was a cross sectional study examining insurance data to determine if there is seasonality related to ED visits and psychiatric hospitalizations related to suicidality.

Suicidality includes both suicidal ideation and suicide attempts (but not suicide).  One survey showed that up to 12% of US adolescents reported serious thoughts of suicide.  This study included 73,123 patients where 19.4% were direct inpatient admissions and 80.6% were ED visits, 44% of whom were subsequently admitted.

Metrics for suicidality in 10-18 year olds peaked in April and October with a nadir in June.  Incidentally, in the Spring of 2020 when US schools closed due to COVID, there was a decrease in both ED visits and hospitalizations with April and May having the lowest rates across the study period.

School is believed to increase stress with risk factors such as bullying and peer pressure, academic and extracurricular stressors and poor sleep hygiene.

Bottom line: There has been an increase in adolescent suicidality over the recent years, many of whom present to the ED for evaluation.  More mental health resources are needed, especially during the school year.

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Category: EMS

Title: Prehospital obstetric events

Keywords: delivery, neonatal, OB, contractions (PubMed Search)

Posted: 5/15/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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Maternal morbidity continues to increase in the US with a mortality rate in 2021 of 39.2 deaths/100,000 live births.  There has been an intense focus on training and quality improvement within hospitals, but not much has changed in the prehospital education arena.  This study aimed to quantify the complications encountered by EMS clinicians.  

In the 2018-2019 EMS dataset used, there were a total of 56,735,977 EMS activations which included 8641 out of hospital deliveries, 1712 documented delivery complications and 5749 records of newborns.

1% of the out of hospital deliveries had a documented complication for the mother.  Of these complications, 94% were for hemorrhage, 6% for abnormal presentation, 0.2% for shoulder dystocia, and 0.4% for nuchal cord.  

Few patients had medications given, including 0.4% receiving oxytocin.  no patients received prehospital blood transfusion or TXA.  Of note, in the years since this data was obtained, TXA and whole blood have started to appear on more medic units, but it is still not necessarily commonplace.

Bottom line: While still rare, prehospital delivery does occur and EMS should be prepared for any possible complications.  Medical directors should look at their jurisdictional/state protocols to see if oxytocin/TXA or whole blood should be included (if not already available).  EMS clinicians should be educated on up to date management of OB emergencies.

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This was a multicenter, randomized double blind, placebo controlled, non inferiority trial looking at children aged 2 months to 10 years with a diagnosis of urinary tract infection to see if the antibiotic course could be shortened from 10 days to 5 days in those patients who have clinically improved by day 5.

Children were prescribed amoxicillin/clavulanic acid, cefixime, cefdinir, cephalexin or trimethoprim-sulfamethoxazole and on day 6, after an in person visit were switched to placebo or continued the same antibiotic course.

A urine sample was collected on days 11-14 and treatment failure was defined as symptomatic urinary tract infection at or before this visit, asymptomatic bacteriuria, positive urine culture or gastrointestinal colonization with resistant organisms.

693 children were randomized in this trial.  Children who received 5 days of antibiotics were more likely to have asymptomatic bacteriuria or a positive urine culture on days 11-14 (0.6 vs 4.2%).  28 children would need to be treated with a 10 day course to prevent one treatment failure with the 5 day course.

Bottom line: 10 days is still the ideal duration of treatment for a urinary tract infection, but the rate of failure of a 5 day course was low and the clinical significance of asymptomatic bacteriuria or a positive urine culture in an otherwise asymptomatic child is unknown.

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Category: EMS

Title: Is a lack of recorded prehospital blood pressure an indicator of pediatric mortality?

Keywords: pediatric trauma, vital signs, blood pressure (PubMed Search)

Posted: 4/17/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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The short answer is yes, pediatric trauma patients without blood pressures recorded from EMS had a higher mortality (4.3%) compared to pediatric patients that did have a recorded blood pressure (1.1%). This is based off of a prehospital study conducted in Japan.

Prehospital vital signs are left out more often in pediatric patients compared to adults. Of those vital signs that are recorded, blood pressure is the most common one left off.

There can be several barriers to obtaining a blood pressure on the pediatric patient in the prehospital setting: lack of properly sized equipment, an uncooperative child, and lack of education. However, the inability to obtain a blood pressure can also be due to the patient being more severely injured and having other skills performed or was unable to be obtained due to poor perfusion. In this study, those who did not have a recorded blood pressure also had a lower GCS score and a higher injury severity score.

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Category: EMS

Title: What can we learn from suicide related cardiac arrests?

Keywords: Suicide, EMS, prevention, causes (PubMed Search)

Posted: 3/20/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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7,365 suicide related cardiac arrests were included in this study that included a several year study period in Queensland Australia.  Cardiac arrests where resuscitation was attempted by EMS and where circumstances were concerning for suicide were included.  ROSC rates were 28.6% with survival at 30 days being only 8%.  30-day survival for medical cardiac arrests in this jurisdiction was 16.4%.  Overdose and poisoning had the best survival rate (19.9%), while hanging and chemical asphyxia were the worst (7.3 and 1.1% respectively).

Bottom line: Survival rates for suicide related out of hospital cardiac arrest were worse compared to other causes of medical arrest.  Suicide prevention should become a focus with emphasis on early identification and treatment of people at high risk of suicide.  While EMS is well trained on the management of cardiac arrest, training should also emphasize suicide risk assessment and identification.

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The gold standard for confirming ETT position is a chest xray, but this can often be delayed while the patient is stabilized. Many physicians will estimate ETT insertion depth to be 3x the ETT size, but this is based on selection of the correct tube.  There are several other published formulas, including the PALS guidelines [age in years/2 + 12] which applies to children older than one year.  In 1982, there was an article published that cited the formulas of [Height (cm) x 0.1 +5] or [Weight(kg)/5 + 12].

This was a retrospective study where the ideal position of cuffed ETT (from the front teeth) was determined by looking at post intubation xrays of 167 patients between 28 days and 18 years.  The individual optimal ETT insertion depth was plotted against age, weight and height for all children.  This study showed that there is not a fully linear relationship between age, height or weight which is a flaw of all of these formulas.  Calculations using the patients’ weight performed the worst.  Age based and height formulas performed the best.

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Category: EMS

Title: Should there be a different set of vital sign "norms" for EMS?

Keywords: vital signs, age, pediatric, prehospital intervention (PubMed Search)

Posted: 2/21/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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Vital signs in children can be difficult to remember since they vary with age.  Using a standardized card or app (such as PALS) can help EMS clinicians remember the values.  Most pediatric vital sign reference ranges were derived from samples of healthy children in the outpatient setting (ie PALS).  This study attempted to validate a range of pediatric vital signs that were more accurate in predicting the need for prehospital interventions compared to the standard PALS vital sign ranges. The thought was that by using EMS data, these vital sign ranges could better alert EMS to patients in need of acute intervention.

The authors used a large EMS database to determine the vital signs for the patients age and correlated that to prehospital interventions (including IV, medication, EKG, advanced airway management, ect).  They used the <10% and >90% for the age values (termed "extreme" vitals signs) as a cut off to be considered abnormal.  Using the EMS derived values, 17.8% of the encounters with an extreme vital sign received medication.  If the PALS abnormal vital sign range was used, only 15.2% of those patients were given medications.  Overall, encounters with an extreme vital sign had a higher proportion of any intervention being performed compared to other vital sign criteria (i.e. only 33.7% with PALS).

These extreme vital signs also had a greater accuracy in predicting mortality.

Bottom line: While vital signs are based on physiology that does not change based on location, using a seperate criteria for the EMS population, can improve discrimination between sick and sicker patients and hopefully allow EMS to recognize and intervene on sicker patients sooner.

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Category: Pediatrics

Title: What is BACM?

Keywords: myositis, acute kidney injury, problems walking, calf pain (PubMed Search)

Posted: 2/14/2024 by Jennifer Guyther, MD (Emailed: 2/16/2024) (Updated: 2/16/2024)
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BACM stands for benign acute childhood myositis which is typically a benign, viral induced self limiting illness.  This was a retrospective study looking at 65 patients in Italy to further characterize the characteristics of the disease.

In this study, the median patient age was 6 years with a male predominance.  The incidence of BACM peaked in winter with a second peak in the fall.  Patients presented with prodromal symptoms including fever, cough, coryza, sore throat and vomiting.  The exam showed difficulty walking and myalgias with reproducible calf tenderness and preserved reflexes.  Influenza B and A, COVID and other viral pathogens have been detected in these patients.

Lab work may show an elevated creatinine kinase, AST and potassium.  WBC and CRP may also be elevated.  The median CK value was 943 U/L and on average normalized within one week.  Other studies have shown median CK values in the 3300s. Treatment includes hydration to promote CK clearance and prevent complications including acute kidney injury related to rhabdomyolysis.  Recurrent myositis or CK values > 5000 U/L should have screening tests for muscular dystrophy and metabolic disorders.

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Category: Pediatrics

Title: Pediatric bounce backs

Keywords: Bouncebacks, high risk discharges, gastroenteritis, death (PubMed Search)

Posted: 1/19/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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Revisits back to the ED within 3 days of the initial visit represent a standard quality measure.  A critical ED revisit was defined as an ICU admission or death within 3 days of ED discharge.  This study looked at 16.3 million children who were discharged from various EDs over a 4 year period and found that 0.1% (18,704 patients) had a critical revisit and 0.00001% (180 patients) died.  

The most common diagnosis at the initial visit of those patients coming back with a critical revisit included: Upper respiratory infections, gastroenteritis/nausea/vomiting and asthma.

The most common critical revisit diagnosis were: asthma, pneumonia, cellulitis, bronchiolitis, upper respiratory infections, respiratory failure, seizure, gastroenteritis/nausea/vomiting, appendectomy and sickle cell crisis. Among the patients who died, 48.9% were younger than 4 years. Patients with complex medical problems and patients seen at a high volume center were more likely to have a critical ED visit.

Bottom line: These ED revisits may not have been related to missed diagnosis (with the exception of appendicitis), but rather due to the natural progression of certain disease processes.  Patients with these diagnoses may benefit from careful reassessment, targeted patient education, more specific return precautions and closer outpatient follow up.

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Category: EMS

Title: Can paramedics accurately risk stratify patients with acute chest pain?

Keywords: ACS, PE, risk stratification (PubMed Search)

Posted: 1/17/2024 by Jennifer Guyther, MD (Updated: 6/22/2024)
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The 2nd most common reason for EMS activation is chest pain.  In this study, paramedics were asked to complete the HEAR (history, EKG, age, risk factor) score, EDACS (ED Assessment of chest pain score), the Revised Geneva Score and the PERC (Pulmonary embolism rule-out criteria) for all patients older than 21 who presented with chest pain.  The positive and negative likelihood ratios (LR) of the risk scores in relation to 30 day MACE and PE risk were calculated.

837 patients were included in this study with 687 patients having all 4 scores completed.   The combination of HEAR/PERC had the best negative LR (0.25) for ruling our MACE and PE at 30 days.   However, these scores, alone or in combination, were not sufficient to exclusively guide treatment or destination decisions.  Adding biomarkers (ie troponin or Ddimer to the prehospital setting) could improve the usefulness of these scores.

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US hospitals have traditionally been concerned that without an ambulance diversion protocol that they would be overrun with EMS arrivals.  EMS had been concerned that without diversion there would be extended wait times at the hospital.  This study looked at EMS arrivals one year (2021) before the elimination of diversion and compared the number to one year after diversion elimination (2022).  

This study of a single level 1 trauma center showed that there was NO difference between the number of EMS arrivals per day (84 vs 83, p = 0.08), time to room for ESI 2 patients, time to head CT in acute stroke patients OR ambulance turn around time (16 min vs 17 min, p = 0.15).

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Urinary tract infection (UTI) is the leading cause of fever without a source in infants younger than 3 months.  This data was collected from patients who presented to the emergency department with fever without a source over a 16 year period.  Out of 2850 patients, 20.8% were diagnosed with a UTI, the majority of which grew E coli.  Of those patients who were diagnosed with UTI, these patients were more likely to have a history of renal/GU problems, have a fever of at least 39C (38% vs 29%) or poor feeding (13% vs 8.7%).  However, 48% had none of these risk factors.  Also 6.1% of patients with a febrile UTI had another invasive bacterial infection.  These patients were more likely to be < 1 month, be "irritable" per parents and have an elevated procalcitonin and CRP.  

Bottom line:  A lack of risk factors can not exclude a UTI in febrile infants < 3 months.  A diagnosis of UTI also does not definitively exclude an additional invasive bacterial infection in a subset of these children.

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Category: Pediatrics

Title: Does the timing of patient transfer impact mortality in the pediatric trauma patient?

Keywords: pediatric trauma, transport, time to destination (PubMed Search)

Posted: 11/17/2023 by Jennifer Guyther, MD (Updated: 6/22/2024)
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Pediatric patients treated at pediatric specific trauma centers have improved mortality.  However, it is estimated that only 57% of patients live within 30 miles of a pediatric trauma center.  This means that many children will need to be stabilized at an adult trauma center or community hospital prior to transfer.  This study showed that > 25% of injured children were transferred to a pediatric trauma center following stabilization at another hospital.
The American College of Surgeons has previously recommended that the optimal interfacility transfer time for trauma patients is 60 minutes.
Data for this study was extracted from a database fed by over 800 trauma hospitals.  Every minute increase in the interfacility transfer time is associated with a 2% increase in risk adjusted odds of mortality among severely injured pediatric trauma patients.
Bottom line: When faced with a moderate to severely injured pediatric trauma patient, the availability and time to transport should be taken into account. If the time is > 60 minutes, then mode of transport and destination (if others are available), should be considered.

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Category: EMS

Title: EMS and the management of pediatric agitation

Keywords: mental health, excited delirium, agitation, sedation, ketamine (PubMed Search)

Posted: 11/15/2023 by Jennifer Guyther, MD (Updated: 6/22/2024)
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This is a retrospective review of pediatric patients with mental health presentations to EMS in Australia.  For children 12 or older, EMS has standing orders for midazolam for mild to moderate agitation and ketamine for severe agitation.  Patients younger than 12 require medical consultation prior to administration.
14% of pediatric EMS calls in this study were for mental health problems.  In 8% of the 7816 pediatric mental health EMS encounters, patients received either midazolam (about 75%) or ketamine (25% of cases). 11% of patients who received midazolam had an adverse event while 37% in the ketamine group had an adverse event.  Adverse events included airway obstruction requiring jaw thrust, OPA or NPA placement, BVM or desaturations requiring oxygen. No serious adverse events occurred in either group.
Police accompanied EMS in 82% of these cases.  Patients who received medication management were more likely to have autism spectrum disorder, post traumatic stress disorder, intellectual disability, psychiatric disorder or history of substance abuse.
Bottom line: Pediatric mental health is a significant global problem where further research is needed.

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Category: Pediatrics

Title: Should an ED thoracotomy be performed in pediatrics?

Keywords: trauma arrest, ROSC, blunt, penetrating (PubMed Search)

Posted: 10/20/2023 by Jennifer Guyther, MD (Updated: 6/22/2024)
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12 pediatric and adult surgeons with pediatric trauma expertise reviewed the literature to form a consensus statement on the indications for ED thoracotomy (EDT) on patients younger than 19 years.  Eleven studies were included for a total of 319 children who underwent EDT.  142 patients had penetrating trauma while 177 sustained blunt trauma.  Survival in the penetrating group was 13.4% and 2.3% in the blunt group.  Many of these patients were 15 and older.  Based on the review of the literature, the group made recommendations:
1) In pediatric patients with signs of life (SOL) who present pulseless in the setting of penetrating trauma, EDT was conditionally recommended.
2) In pediatric patients without SOL who present pulseless in the setting of penetrating thoracic trauma EDT was conditionally NOT recommended.  
3)  In pediatric patients with SOL who present pulseless in the setting of penetrating abdominopelvic trauma EDT was conditionally recommended.  
4) In pediatric patients without SOL who present pulseless in the setting of penetrating abdominopelvic trauma EDT was conditionally NOT recommended.  
5) In pediatric patients with SOL who present pulseless in the setting of blunt trauma EDT was conditionally recommended AFTER emergency adjuncts which include ultrasound and thoracostomies.  
6)  In pediatric patients without SOL who present pulseless in the setting of blunt trauma EDT was NOT recommended.  
SOL included cardiac electrical activity, respiratory effort, pupillary response, pulses, blood pressure, or extremity movement.
Bottom line:  If the pediatric trauma patient presents pulseless, but with SOL, EDT can be considered.  However, evidence is still very limited, especially in children < 15 and these recommendations are conditional.

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Category: EMS

Title: Which type of BVM provides appropriate tidal volumes in the back of an ambulance?

Keywords: BVM, tidal volume, TV, ALS, BLS (PubMed Search)

Posted: 10/18/2023 by Jennifer Guyther, MD (Updated: 6/22/2024)
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The typical bag valve mask ventilator (BVM) for adults has a reservoir volume between 1500-2000 mL depending on the manufacturer while the volume is between 500-1000 mL for a pediatric BVM.  When trying to obtain the recommended tidal volume of 6-8 mL/kg (500-600 mL for the typical adult), one thought was that a pediatric BVM could be used with adult patients so as to avoid iatrogenic barotrauma.  This has been studied on manakins using an oral pharyngeal airway, supraglottic airway and endotracheal tubes (ETT) and has been successful.  This study attempted to obtain the same results in the back of a moving ambulance.  Paramedics and EMTs, squeezing pediatric and adult BVMs with one hand, bagged adult manakins in the back of a moving ambulance (without lights and sirens).  The average tidal volume was recorded using various types of airways (i-gel, King airway and ETT).

Volumes delivered with the pediatric BVM were significantly lower than the tidal volumes with adult BVMs across all airway types suggesting that in the moving ambulance, using pediatric BVMs on an adult patient would not be appropriate.

The I-Gel and King airway provided similar tidal volumes which were not statistically different than volume delivered through the ETT.

EMTs consistently delivered 50% less tidal volumes compared to paramedics. The authors suggested that perhaps the additional training and pathophysiology knowledge that paramedics have could also be important with a skill that is considered basic. 

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Category: EMS

Title: What are the barriers for laypeople to be trained in CPR?

Keywords: cardiac arrest, CPR, bystander (PubMed Search)

Posted: 9/20/2023 by Jennifer Guyther, MD (Updated: 6/22/2024)
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Prior studies have shown that CPR education is associated with a greater willingness to perform CPR.  This was a review of 23 studies to determine factors that enable and hinder a layperson from learning CPR.
Enabling factors included having witnessed someone collapse in the past, awareness of public AEDs, certain occupations and legal requirements for training (i.e. mandatory high school CPR training).
Married people were more likely to be trained than those that were not married and people with children younger than 3 years were less likely to take a BLS course.  
Barriers that were found to impact people taking CPR classes included lower socioeconomic status and education level, and advanced age and language barriers.  
Bottom line: CPR education sessions should target groups with these identified barriers.

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Category: Pediatrics

Title: Spontaneous Pneumomediastinum in Children: What should I do?

Keywords: Spontaneous Pneumomediastinum, asthma, crepitus, esophagram (PubMed Search)

Posted: 9/15/2023 by Jennifer Guyther, MD
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Spontaneous pneumomediastinum (SPM) is air within the mediastinum in the absence of trauma.  This occurs more often in males and has 2 age peaks: children younger than 6 years as a result of lower respiratory tract infections and adolescents due to asthma exacerbations.  Typical symptoms include chest pain, subcutaneous emphysema and shortness of breath, but can also include neck pain, dysphagia, pneumopericardium, and pneumorrhachis (air in the spinal cord).   SPM has been seen in patients with a history of asthma, current influenza infection and hyperventilation with anxiety, but many have no known precipitating factor. 
The diagnosis of SPM is typically made on CXR.  The literature is mixed on the utility of CT scans, esophagrams, esophagoscopy and bronchoscopy.  This study looked at 179 pediatric patients who were diagnosed with SPM.  No patients were found to have an esophageal injury.  Also, CT scans did not provide additional information or change management based on what was seen on the chest xray.
The author's concluded that CT scans and esophagrams can be avoided unless there is a specific esophageal concern.  Management should be guided based on the patient's symptoms.

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