UMEM Educational Pearls - By Jenny Guyther

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

Category: EMS

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

Posted: 1/17/2024 by Jenny Guyther, MD (Updated: 11/22/2024)
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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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Title: Does EMS diversion impact the number of ambulances that arrive at a particular facility?

Category: EMS

Keywords: EMS, red, yellow, divert, capacity (PubMed Search)

Posted: 12/20/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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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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Title: What should make me think about UTI as a cause of fever in children younger than 3 months?

Category: Pediatrics

Keywords: fever, SBI, infants (PubMed Search)

Posted: 12/15/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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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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Title: Does the timing of patient transfer impact mortality in the pediatric trauma patient?

Category: Pediatrics

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

Posted: 11/17/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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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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Title: EMS and the management of pediatric agitation

Category: EMS

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

Posted: 11/15/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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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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Title: Should an ED thoracotomy be performed in pediatrics?

Category: Pediatrics

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

Posted: 10/20/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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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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Title: Which type of BVM provides appropriate tidal volumes in the back of an ambulance?

Category: EMS

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

Posted: 10/18/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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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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Title: What are the barriers for laypeople to be trained in CPR?

Category: EMS

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

Posted: 9/20/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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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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Title: Spontaneous Pneumomediastinum in Children: What should I do?

Category: Pediatrics

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

Posted: 9/15/2023 by Jenny 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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Title: Pediatric drowning what are the risk factors?

Category: Pediatrics

Keywords: Drowning, near drowning, CXR (PubMed Search)

Posted: 8/18/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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This was a retrospective study involving several hospitals in Italy. 135 patients who had drowned (the term used in the article) were included. 4.5% of patients died. Most drowning occurred in July and August. The most common comorbidity was epilepsy in about 10% of patients. Several patients were also witnessed to have trauma and syncope. Early resuscitation, either by bystanders or trained professionals, was paramount in survival.

Children who are conscious at presentation and have mild or no respiratory distress have the best prognosis. A well appearing child should be observed for 6-8 hours, given that 98% of children will present with symptoms within the first 7 hours. A chest xray is not indicated in the asymptomatic patient. Patients who are submerged greater than 25 minutes or without ROSC after 30 minutes have a poor prognosis.

Bottom line: Never swim alone and everyone should be trained in bystander CPR.

Title: What are the barriers to 911 being able to direct hands only CPR instructions to callers?

Category: EMS

Keywords: Hands only CPR, bystander CPR, directions (PubMed Search)

Posted: 8/16/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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Bystander CPR increases out-of-hospital CPR survival and direction by 911 telecommunicators increases the frequency of bystander CPR. The majority of 911 centers use Medical Priority Dispatch System which walks 911 telecommunicators through a series of questions that give different instructions based on the caller's answers. Studies have shown out-of-hospital cardiac arrests are only recognized between 79-92% of the time and telecommunicator instructions for CPR can take between 176-285 seconds.

This study reviewed recorded 911 calls of patients who were found to be in cardiac arrest. Calls where the caller was not with the patient and confirmed overdoses were some of the call types that were excluded.

Out of 65 reviewed calls, 28% were not recognized during the actual call. When they were reviewed, 8/18 of the calls were deemed to be recognizable. Themes that were noted were: incomplete or delayed recognition assessment (ie uncertainty in breathing), communication gaps (callers were confused with instructions or questions), caller emotional distress, delayed repositioning for chest compressions, non essential questions and assessments, and caller refusal/hesitation or inability to act.

Bottom line: In addition to bystander CPR training, education on the process and questions involved in calling 911 could be helpful in an emergency.

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Title: Should blood cultures be drawn in a child with fever and lower extremity pain?

Category: Pediatrics

Keywords: fever, limp, bacteremia, osteomyelitis, septic joint (PubMed Search)

Posted: 7/21/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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This was a cross sectional review of 698 patients ages 1 year to 18 years who presented to a tertiary care center with fever of at least 38 degrees centigrade and non traumatic acute lower extremity pain. This hospital was located in the North East of the United States. Lower extremity pain was defined as an antalgic gait by report or on exam, inability or refusal to bear weight or reported bone or joint pain in the verbal patient within the past 14 days.

Blood cultures were available for review in 510 patients. Blood cultures were positive in 70 of them (13.7%). Pathogens included MSSA, MRSA, Strep pyogenes and Salmonella. Significant predictors of bacteremia included an elevated CRP and localizing exam findings.

8 blood culture contaminants were identified. 6/8 of these patients had other testing and treatment consistent with osteomyelitis.

The final diagnosis of the patients with bacteremia included osteomyelitis, septic arthritis, pyomyositis and toxic shock syndrome.

Bottom line: The prevalence of bacteremia, even in Lyme endemic areas, in healthy children presenting to the ED with fever AND lower extremity pain is high enough to strongly consider obtaining a blood culture with other lab work during the initial evaluation.

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Title: ED handoff of pediatric patients by EMS

Category: EMS

Keywords: handoff, communication, adverse outcomes (PubMed Search)

Posted: 7/19/2023 by Jenny Guyther, MD
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Ineffective handoff communications have been shown to occur in up to 80% of medical errors. Previous studies have shown that up to 1/3 of pertinent information is lost during the handoff of trauma patients. Interruptions, lack of listening and ED team preoccupation with their own patient assessment have been associated with adverse outcomes.

This study reviewed videotaped footage of pediatric critical care resuscitations and the handoff between the ED and EMS. Inefficient communication occurred in 87% of handoffs, including 51% of cases with interruptions by staff, 40% with questions from the ED leader about information that had already been given and 65% requesting information that had not yet been communicated.

Bottom line: Allow for an uninterrupted hand off from EMS followed by closed loop communication and asking any additional questions.

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Title: In light of recent July 4th celebrations, lets talk about burns! Submitted by Dr. To-Lam Nguyen

Category: Pediatrics

Keywords: burns, pediatric (PubMed Search)

Posted: 7/7/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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Burns are common pediatric injuries and usually represent preventable unintentional trauma.

Approximately 10% of children hospitalized with burns are victims of abuse. Thermal burns are the most common type of burn and can result from scalding injuries or contact with objects (irons, radiators, or cigarettes). Features of scald burns that are concerning for inflicted trauma include clear lines of demarcation, uniformity of burn depth and characteristic pattern. Abusive contact burns tend to have distinct margins (branding of the hot object), while accidental contact burns tend to have less distinctive edges

How Kids are Different than Adults:

- Kids have thinner skin, so time to burn/energy required to cause a burn is less.

- Kids have increased blood volume relative to their mass, so may need more volume resuscitation compared to adults.

- Kids are more likely to become hypoglycemic so give glucose in mIVF in kids <20 kgs.

- Risk of airway compromise in kids following inhalation injury is higher due to their smaller airway openings

Treatment:

- Initial treatment should follow ABCs of resuscitation

- Airway: Airway management should include assessment for presence of airway or inhalation injury, with early intubation if such an injury is suspected. Smoke inhalation may be associated with carbon monoxide toxicity; 100% humidified oxygen should be given if hypoxia or inhalation is suspected.

- Circulation: Parkland's formula

- Fluid requirements = TBSA burned (%) x weight (kg) x4mL

- Give ½ of total requirements in 1^st 8 hours, then give 2^nd half over the next 16 hours.

- REMEMBER KIDS HAVE BIG HEADS

- Rule of 9's for adults: 9% for each arm, 18% for each leg, 9% for head, 18% for front torso, 18% for back torso

- Rule of 9's for children" 9% for each arm, 14% for each leg, 18% for head, 18% for front torso, 18% for back torso.

Options for pain management

- fentanyl IN

- morphine IV

- ketamine IV

Burns you should consider admission

- >6% TBSA

- full thickness burns

- specialty areas: face, eyes, airway, genitalia, palmar crease, sole of foot

- concern for non-accidental injury

- caused by treadmill

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Title: What are risk factors in ambulance crashes?

Category: EMS

Keywords: ambulance, crash, response, fatality, collision (PubMed Search)

Posted: 6/22/2023 by Jenny Guyther, MD
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Between 2010 and 2020, there were 279 fatalities related to ambulance accidents. In up to 50% of accidents, EMS is not at fault. The use of lights and sirens and intersections have been previously shown to be the most common risk factor for accidents. There is a national push for a more judicious use of lights and sirens.

Most ambulance crashes are minor, but up to 1/3 of crashes can result in significant injury or significant damage to the vehicle. This study attempted to relate driver demographics and aggressive driving behavior to ambulance crashes using a vehicle telematics system. The agency in this study responded to about 130,000 calls per year and the incident rate of any crash was 2.1/100,000 miles and the incident rate of a serious crash was 0.63/100,000 miles. Injuries occured in 8% of the 214 crashes over the 3 year study period. One third of the cases resulted in significant vehicle damage. Female sex and age 18-24 were found to be independently associated with a collision.

Bottom line: Transporting patients via ambulance, especially when lights and sirens are used, is not a risk free event. Even if injuries do not occur, the impact of damage to the vehicle can significantly impact the EMS system.

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Title: Omphalitis

Category: Pediatrics

Keywords: neonatal fever, cellulitis, bacteremia (PubMed Search)

Posted: 6/16/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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Omphalitis is a soft tissue infection involving the umbilicus and surrounding tissues with redness and induration around the umbilical stump. Risk factors include: prematurity, prolonged rupture of membranes, maternal infection, low birth weight, history of umbilical catheter and home birth. Pathogens include Staph, Strep and Gram Negative bacteria. Studies have shown that bacteremia can be present in up to 13% of cases.

Omphalitis most often occurs in infants 8-22 days. If fever is present, the AAP guidelines for neonatal fever should be followed. In the well appearing, afebrile infant, blood cultures should be obtained, but CSF studies are not reflexively indicated. Since urachal anomalies can be present in up to 1/4 of these patients, urine studies should be obtained and an ultrasound can be considered if drainage is present. A surface culture should be obtained when possible as well.

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Title: IV placement prior to interfacility transport by private vehicle - is it safe?

Category: Pediatrics

Keywords: IV, EMS, transfer, pediatrics (PubMed Search)

Posted: 5/19/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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This study looked at "low risk" patients who were being transferred from a community hospital to the system quaternary referral center. Patients were selected by the referral center as low risk (closed fracture requiring reduction, eye problems, minor burns, laceration, ect) for transport by personnel vehicle (POV) regardless of IV status. The families were then approached for consent.

Patients had to be between 4-17 years, without social concerns, unreliable transportation or communication differences.

78 patients were eligible with 67 patients electing transport by POV. All patients arrived safely. 29 patients had IVs in place. Procedures were in place by the sending facility to secure the IV, educate the parents about IV care and supplies in case of dislodgement were given. The drive was about 40 minutes. All IVs were functional on arrival at the referral center and there were no noted complications.

Surveys were given to the patients' families and the results were overall positive. The one negative point of feedback involved traffic and navigational difficulties.

Bottom line: In the appropriately selected patient, safe interfacility transport via POV is possible, even when an IV is in place.

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Title: What do caregivers think of alternate EMS dispositions for pediatric patients?

Category: Misc

Keywords: EMS, Alternate destinations, pediatric, EMS, reduce transport times (PubMed Search)

Posted: 5/17/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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Pediatric patients represent up to 10% of EMS transports, but studies suggest that between 10-60% of these patients can be safely transported by alternate means. Many EMS agencies have begun to implement alternate destination programs for adult patients - including transport to an urgent care center, using a taxi service instead of an ambulance, or utilizing telehealth services. One of the first steps in being able to expand these program into the pediatric population involves determining the caregivers perspectives on the concept of not being taken directly to an emergency department when 911 is called.

This study conducted focus groups in English and Spanish which included a total of 38 participants in the Washington DC area. Key take away points include:

1) The reasons for calling 911 for a non emergent reason were multifactorial and included lack of transportation, lack of health insurance, uncertainty about the severity of the patient's complaint and difficulty with after hours primary care access.

2) Most participants were not familiar with alternate EMS disposition programs.

3) Most caregivers preferred telemedicine over telecommunication.

4) Caregivers worried that there would be a delay in care if their child had a genuine medical emergency or decompensation. They were also concerned that there would not be pediatric resources and expertise at the alternate destination requiring a second transport. Also, there were concerns about the coordination between 911, clinics and EMS. Concerns about transportation included vehicle cleanliness and hygiene and provision of appropriate car seats.

Bottom line: Alternate destination for EMS is possible with pediatric patients, but the programs need to take into consideration the above parental concerns in order to be successful.

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Title: Ketamine vs opiates for pediatric pain management

Category: Pediatrics

Keywords: Ketamine, morphine, fentanyl, pediatrics, EMS, pain control (PubMed Search)

Posted: 4/21/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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Multiple modalities are available for pain control in the pediatric setting. Ketamine has recently been introduced into the prehospital environment as an alternative to opiates (fentanyl and morphine). This study examines how ketamine and opiates compare in relation to pain reduction and adverse events.

9223 patients (< 18 years) were included with data from the ESO Collaborative. 190 patients received ketamine (2.1%) and 9033 received opiates (97.9%). Ketamine was associated with a greater reduction in pain score (-4.4 vs -3.1) compared to opiates and a greater reduction in EMS clinician reported improvement. Patients in the ketamine group did have a reduction in the GCS by -0.3 points. There were no patients who required ventilatory support in the ketamine group and one patient who required support in the opiate group. No patients in either group required intubation or died. This study did not examine medication doses or route.

Bottom line: Both ketamine and opiates are viable pain control options for pediatric patients in the prehospital environment.

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Title: Is croup caused by COVID more severe compared to other etiologies?

Category: Pediatrics

Keywords: Croup, respiratory distress, stridor, URI (PubMed Search)

Posted: 3/17/2023 by Jenny Guyther, MD (Updated: 11/22/2024)
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Patients with croup often present with a "barky" cough, stridor, and trouble breathing, traditionally worse at night. The mainstay of treatment is a dose of dexamethasone and if there is moderate to severe distress, racemic epinephrine is added. Croup has typically been caused by viruses, mainly parainfluenza, but influenza, non-COVID coronavirus, adenovirus and RSV have also been shown to cause croup.

When COVID variant Omicron BA.1 became the dominant strain, the rate of pediatric emergency department visits and hospitalizations due to croup were noted to increase. This retrospective study of 499 pediatric patients showed that those who tested positive for COVID within one week of presentation had a significantly higher degree of stridor at rest, hypoxia, the need for additional doses of racemic epinephrine, admission to the floor, admission to the intensive care unit and increasing respiratory support.

Bottom line: Consider testing for COVID in your croup patient who is not responding to traditional therapies.