Department of Emergency Medicine

UMEM Educational Pearls - By Jenny Guyther

Title: Does purulent eye discharge need to be treated topically in pediatrics?

Category: Pediatrics

Keywords: conjunctivitis, pink eye, eye drops (PubMed Search)

Posted: 2/17/2023 by Jenny Guyther, MD (Updated: 11/24/2024)
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It is often difficult to clinically differentiate between viral and bacterial conjunctivitis, but previous studies have shown that the vast majority of the discharge is bacterial. Topical antibiotics are often prescribed, but the efficacy of these antibiotics compared to no treatment has not been well studied.
This study included 88 children aged 6 months to 7 years with acute infective conjunctivitis who were randomized to receive moxifloxacin eye drops, placebo eye drops or no intervention.  Acute infective conjunctivitis was defined as conjunctival inflammation, discharge, soreness or swelling of the eyelids.  The clinical cure was significantly shorter in the moxifloxacin group compared to the no intervention group (3.8 vs 5.7 days).  Both moxifloxacin and placebo eye drops had a shorter time to clinical cure compared to placebo suggesting that placebo eye drops may be beneficial due to their washout effect.
Bottom line: Topical antibiotics for acute infective conjunctivitis were associated with significantly shorter recovery times from acute infective conjunctivitis.

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Title: Advanced airway management in pediatric prehospital cardiac arrest

Category: Pediatrics

Keywords: intubation, supraglottic, BVM (PubMed Search)

Posted: 1/20/2023 by Jenny Guyther, MD
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Should EMS place an advanced airway in out of hospital cardiac arrests?  Current studies suggest that advanced airway management is not superior to BVM in pediatric out of hospital cardiac arrest (OHCA).  

Pediatric OHCA carries a high mortality rate and those that do survive often have a poor neurologic outcome.  This study evaluated BVM vs supraglottic airway (SGA) placement vs endotracheal intubation (ETI) in relation to one month survival and favorable neurological outcomes.  SGA and ETI were also grouped together and categorized as advanced airway management (AAM).

This study was conducted using the Pan Asian Resuscitation Outcomes Study Clinical Research Network.  3131 pediatric patients were included.  85% received BVM, 11.8% SGA and 2.6 % ETI.  In a matched cohort, one month survival and survival with favorable neurological outcome was higher in the BVM group compared to the AAM group and in the BVM group compared to the SGA group.  There was no significant difference noted between the ETI group and BVM group.

Bottom line: In this study, AAM was associated with decreased one month survival and less favorable neurological status in pediatric OHCA.

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Title: Do I need to repeat the potassium level in a hemolyzed sample in the pediatric patient?

Category: Pediatrics

Posted: 12/16/2022 by Jenny Guyther, MD (Updated: 11/24/2024)
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Pseudohyperkalemia can result from the use of small bore IVs, excessive tourniquet time, fist clenching and mechanical stress during collection.  These factors may affect pediatric blood draws. 
 
This was a 5 year retrospective analysis of patients 0-17 years.  187 patients had a hemolyzed sample that showed hyperkalemia.  145 children had repeat testing and only 3 children had true hyperkalemia (2%).  All three of these patients had underlying conditions that would have raised suspicion for hyperkalemia (chronic renal failure and diabetic ketoacidosis).  There were no abnormalities to the BUN or creatinine in the patients without hyperkalemia.
 
Bottom line: This small study suggests that it may not be necessary to obtain repeat blood samples for hyperkalemia in patients with normal BUN and creatinine.  Larger studies are needed before bringing this into mainstream practice.

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Title: What is the proper ratio of blood products in the bleeding pediatric trauma patient?

Category: Pediatrics

Keywords: Pediatric trauma, blood transfusion, ratios (PubMed Search)

Posted: 11/18/2022 by Jenny Guyther, MD (Updated: 11/24/2024)
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Research in the pediatric trauma patient has finally shown that crystalloid volume should be limited and blood products should be used early in resuscitation.  Whole blood transfusion is currently being studied.  Studies are also being conducted looking at the proper ratio of blood products for these pediatric trauma patients.
This was a retrospective review of the Trauma Quality Improvement Program.  Patients younger than 18 years old who received at least 1 unit of FFP and PRBCsduring the initial 4 hours of admission were included.  The study looked at 1,233 patients who received FFP:PRBC ratios of 1:1, 1:2, 1:3 and 1:3+ and 24 hour mortality, hospital mortality, complications and 24 hour PRBC requirements.
The 1:1 transfusion group had the lowest 24 mortality and in-hospital mortality.  There was no difference between the groups for complications.  The 1:1 ratio group also had the lowest 24 hour PRBC requirements.  This study did not include those patients who required massive transfusion on arrival. 
Bottom line: FFP:PRBC ratio of 1:1 was associated with increased survival in children.  More studies are needed regarding whole blood and massive transfusion in pediatrics.

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Title: Once intuccesption has been diagnosed, when should reduction occur?

Category: Pediatrics

Keywords: intuccesption, air enema, reduction timing (PubMed Search)

Posted: 10/21/2022 by Jenny Guyther, MD (Updated: 11/24/2024)
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Once the diagnosis of intussusception is made, there are often delays in 1) getting the patient to a center where reduction can be performed and 2) getting the staff available to perform an air enema, especially during evenings and nights. Previous studies have shown worse outcomes when there is longer than a 24 hour delay in reduction. This was a retrospective single center study looking at 175 cases of intussusception and evaluating the time between the radiology final read of intussusception and the timing of reduction and if enema based reduction was successful. In this group of patients, there was no statistically significant difference in reduction efficacy, requirement for surgical reduction or complication rate (bowel resection or perforation) in the patients studied which included delay intervals up to 8 hours. Successful first attempt reductions ranged from 72-81% in each study group (1hr, 1-3hr, 3-6hr and 6+ hr). The caveat to this study is that there were only 11 patients included in the 6-8 hour group. This study also did not take into account the timing from symptom onset to reduction time. Bottom line: More evidence is needed, but this small study provides evidence that up to 8 hours from radiology diagnosis of intussusception to the 1st reduction attempt was not less efficient compared to those with an attempt in under 1 hour.

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Title: What factors increase the risk of laryngospasm during pediatric procedural sedation?

Category: Pediatrics

Keywords: pediatrics, moderate sedation, airway, laryngospasm. (PubMed Search)

Posted: 9/16/2022 by Jenny Guyther, MD
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Laryngospasm is defined as the cessation of ventilation despite persistent respiratory effort related to glottic closure.  Complications include hypoxia, bradycardia, and cardiac arrest.  In OR cases, one recent study found the laryngospasm to occur in 0.45/1000 cases.  In these children undergoing general anesthesia, risk factors included current upper respiratory infection, active asthma, airway anomalies, airway procedures, age < 3 months and the use of an LMA.  
Studies of the rates of laryngospasm in pediatric sedation have shown varied incidence, with prevalence between 0.43/1000 to 2.1/1000.  A metaanalysis showed that laryngospasm was more common with a combination of propofol and ketamine.
This study looked at moderate sedation cases where laryngospasm was not relieved with chin repositioning or the use of an airway adjunct.  Over a 7 year study period, 276,832 sedations were examined with 913 patients experiencing laryngospasm (3.3/1000 cases).  About 5% of these patients required intubation.  There were 2 cases of cardiac arrest, one with an underlying cardiac condition and one with a URI who was undergoing an echo.  Both of these patients had multiple agents used for sedation.
The isolated use of IV ketamine had a laryngospasm rate of 1.4/1000 cases.  The highest prevalence occured with propofol + ketamine (6.6/1000), propofol + midazolam + opiate (6.1/1000) and propofol + dexmedetomidine (5.8/1000).
The risk of laryngospasm was associated with a higher ASA status, younger age, presence of a URI, airway procedures, and certain propofol combination regimens.
Bottom line: While the prevalence of laryngospasm remains low during pediatric sedation, risk factors should be taken into consideration and the risk/benefits should be discussed in detail with the families.  Always be prepared for an airway emergency during sedation.

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Title: Secondary Transmission of SARS-CoV2 with regards to Masking in Schools

Category: Pediatrics

Keywords: COVID, kids, masking, school (PubMed Search)

Posted: 8/19/2022 by Jenny Guyther, MD (Updated: 11/24/2024)
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This was a multistate, prospective, observational cohort of children and teachers attending in person schools in kindergarden through 12th grade where the school districs had the ability to perform contact tracing and determine primary vs secondary infections.  During the study period (6/21-12/21) 46 districts had universal masking policies and 6 districts had optional masking policies.  

Districts that optionally masked had 3.6x the rate of secondary transmission compared to universally masked school districts.  Optionally masked districts had 26.4 cases of secondary transmission per 100 community acquired cases compared to only 7.3 cases in universally masked districts.

Bottom line: Universial masking was associated with reduced secondary transmission of SARS-CoV2 compared with optional masking policies. 

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Title: The Pediatric Pause - Introducing a Trauma Informed Care Protocol

Category: Pediatrics

Keywords: trauma informed care, pediatric resuscitation (PubMed Search)

Posted: 7/15/2022 by Jenny Guyther, MD (Updated: 11/24/2024)
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Traumatic injuries are a leading cause of morbidity and mortality in pediatric patients.  Even in the setting of a full recovery, there can be negative psychological sequelae associated with the traumatic events.  The child's perceived risk of death and parental trauma related distress have both been associated with the development of post traumatic stress.
 
Previous studies have suggested the key components of trauma informed pediatric care include: minimizing potentially traumatic aspects of medical care and procedures, providing children and family with basic support and information, addressing child distress such as pain, fear, and loss,  promoting emotional support, screening children and families who might need support and providing anticipatory guidance about adaptive ways of coping.
 
The Pediatric PAUSE was introduced at a pediatric trauma center to help to reduce post traumatic stress.  
 
PAUSE stands for Pain/Privacy, Anxiety/IV access, Urinary Catheter/Rectal Exam/Genital Exam, Support for family or staff and Explain to patient/Engage the PICU team.  The article contains a table with a more detailed outline of the PAUSE.
 
This study evaluated the pediatric PAUSE to see if its implementation would interfere with the timeliness of the ACS/ATLS evaluation.  The PAUSE was inserted after the primary and ABCDE assessment (except in the unstable patient).  The use of this protocol did not prolong time between trauma bay arrival and critical imaging studies.

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Title: What is the ideal length of treatment for pediatric community acquired pneumonia?

Category: Pediatrics

Keywords: PNA, pediatrics, duration of treatment (PubMed Search)

Posted: 6/17/2022 by Jenny Guyther, MD (Updated: 11/24/2024)
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This was a randomized placebo controlled trial looking at 380 pediatric patients aged 6 months to 5 years who were diagnosed with nonsevere CAP and who showed early clinical improvement.  On day 6, one patient group was switched to a placebo while the other group continued with the antibiotics.
 
In this small study population, 5 days of a penicillin based antibiotic had a similar clinical response and antibiotic associated adverse effect profile compared to a 10 day course.  A 5 day course also reduced antibiotic exposure resistance compared to a 10 day course.  

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Title: Post fracture pain management in children.

Category: Pediatrics

Keywords: motrin, narcotics, oxycodone, fracture care (PubMed Search)

Posted: 5/20/2022 by Jenny Guyther, MD (Updated: 11/24/2024)
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This was a prospective study done in a pediatric emergency department where 329 children ages 4-16 years with isolated fractures were included.  After casting, children were prescribed either ibuprofen or oxycodone.  Pain score and activity level were followed by phone for 6 weeks.  The reduction in pain was comparable for motrin and oxycodone.  However, the children who received motrin experienced less side effects and quicker return to baseline activities compared to oxycodone.
Bottom line: Ibuprofen is a safe and effective option for fracture related pain and has fewer adverse effects compared to oxycodone.

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Title: Which pediatric patients with blunt abdominal trauma are at very low risk of significant intraabdominal injury (and so don't need a CT scan)?

Category: Pediatrics

Keywords: abdominal trauma, MVC, CT scans, radiation (PubMed Search)

Posted: 4/15/2022 by Jenny Guyther, MD (Updated: 11/24/2024)
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In 2013, the Pediatric Emergency Care Applied Research Network developed a prediction rule to identify patients who were at low risk of requiring acute intervention after blunt abdominal trauma.  Interventions included laparotomy, embolization, blood transfusion or IV fluids for more than 2 nights with pancreatic or bowel injuries.
If ALL of the following are true, the patient is considered very low risk (0.1%) of needing an acute abdominal intervention:  
- No evidence of abdominal wall trauma or seat belt sign
- GCS 14 or 15
- No abdominal tenderness
- No thoracic wall trauma
- No abdominal pain
- No decreased breath sounds
- No vomiting
 
This prediction rule was externally validated in 2018 showing a sensitivity of 99%.  This rule should be used to decrease the rate of CT scans of the abdomen following blunt trauma.

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Title: Pneumonia Risk Score for pediatric pneumonia.

Category: Pediatrics

Keywords: peds, chest xray, pneumonia. (PubMed Search)

Posted: 3/18/2022 by Jenny Guyther, MD
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In emergency departments in the US, the diagnosis of pneumonia is often made on chest xray.  In the outpatient setting, national guidelines focus on the clinical diagnosis of pneumonia and recommend against radiographs.  This study aimed to develop and validate a clinical tool that could be used to determine the risk of radiographic pneumonia.
The criteria in the Pneumonia Risk Score (PRS) evaluate for the presence of fever, rales, and wheeze and take into account age and triage oxygen saturation.  When developing this protocol, the investigators compared the patients who had pneumonia on chest xray with both clinical judgment and the PRS.  The PRS outperformed clinical judgment in predicting which patients would have pneumonia on chest xray.
Children who have a score of 2 or less were unlikely to have pneumonia on chest xray and would qualify for observation without an xray or empiric antibiotics use.  Children who had a score of 5 or greater were likely to have radiographic pneumonia and could be empirically treated with antibiotics. If the PRS score was 6, the specificity was 99.9%
This link https://links.lww.com/INF/E552. takes you to the excel spreadsheet where you can enter the patients clinical data and gives you a present probability of radiographic pneumonia.  (In case the link does not work, it is also found in the supplemental digital content.)
Bottom line: PRS outperforms clinical judgment when determining if pneumonia will be present on the pediatric chest xray.

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Title: Pediatric Mortality at Pediatric versus Adult Trauma Centers

Category: Pediatrics

Keywords: pediatric trauma, complications (PubMed Search)

Posted: 2/18/2022 by Jenny Guyther, MD
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This study looked at just over 10,000 children using the National Trauma Data Bank between 2011 and 2012. Patients were divided into two age groups: 0 to 14 years and 15 to 18 years. Primary outcomes were emergency department and inpatient mortality depending on whether they were taken to a pediatric versus adult trauma center. Secondary outcomes included hospital length of stay, complication rate, ICU length of stay and ventilator days.

Children in the 0-14 year age group had lower ED and inpatient mortality when treated at pediatric trauma centers. This age group was also more likely to be discharged home and have fewer ICU and ventilator days when treated at the pediatric trauma centers.

There was no difference in ED mortality or inpatient mortality in the 15 to18 year-old age group to pediatric and adult trauma centers. There were no differences in complication rates in any age group between pediatric and adult trauma centers. 
 
Bottom line: Children aged 0-14 should ideally be evaluated primarily at pediatric trauma centers.

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Title: Risk factors for severe COVID in children

Category: Pediatrics

Keywords: pediatrics, COVID, vaccination, hospitalization (PubMed Search)

Posted: 1/21/2022 by Jenny Guyther, MD
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This recently published study was conducted from May 2020 to May 2021 and included 3106 hospitalized pediatric patients with COVID 19 over 14 states.  2293 children were admitted due to their COVID symptoms.  30% of these patients had severe COVID (ICU admission, mechanical ventilation or death) and 0.5% died.
32.5% of admitted patients were younger than 2 years.  More than half of the patients had at least one medical condition.  The most common underlying conditions were obesity, chronic lung disease, neurologic disorders, cardiovascular disease and blood disorders.
Although this data was collected prior to the US presence of both the delta and omnicron variants and public availability of vaccination in 5-11 year olds, this study has identified children at potentially higher risk of severe COVID who may benefit from prevention efforts that include vaccination. 

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Title: The dangers of monkey bars

Category: Pediatrics

Keywords: orthopedics, upper extremity fractures, playgrounds (PubMed Search)

Posted: 11/19/2021 by Jenny Guyther, MD
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While playgrounds can be enjoyable for children, they are a land mine for possible injuries.  In a study looking at playground safety in Australia, monkey bars were the leading cause of upper extremity fractures.  The fractures caused by monkey bars were also more likely to require reduction or operative fixation.  The risk of fracture significantly increases after a fall above 1.5 meters.  Children ages 5-9 years were the most susceptible to playground falls.
Why does this matter?  Playgrounds have made modifications to prevent other types of injury (such as the modification of the playground surface to prevent head injuries).  Reduction in the height of monkey bars, may reduce or limit the severity of these upper extremity fractures.  

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Title: Is IN midazolam non inferior to IM or IV midazolam for the prehospital treatment of pediatric non traumatic seizures?

Category: Pediatrics

Keywords: seizure, status epilepticus, midazolam (PubMed Search)

Posted: 10/15/2021 by Jenny Guyther, MD (Updated: 11/24/2024)
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This was a retrospective, noninferiority analysis looking at patients 14 years old and younger treated for nontraumatic seizures by EMS with a midazolam dose of 0.1 mg/kg (regardless of route).  There were just over 2000 patients with a median age of 6 years included in the study.  Midazolam redosing occurred in 25% of patients who received intranasal midazolam versus only 14% who received midazolam via intramuscular, intravenous, or intraosseous routes.
Bottom line: In the prehospital setting, intranasal midazolam at a dose of 0.1 mg/kg was associated with an increased need to redose compared to other routes.  This dose may be subtherapeutic for intranasal administration.

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Title: Amusement park safety

Category: Pediatrics

Keywords: roller coasters, summer, death (PubMed Search)

Posted: 9/17/2021 by Jenny Guyther, MD
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Over a one year study period, 182 accident events at amusement parks were reported in the news from 38 countries.  51 events involved a fatality. Mechanical rides and roller coasters were involved in 87 events. 
- The risk of injury associated with spending a day at an amusement park is very low, but not non-existent.
- The high g forces of certain thrill rides (ie roller coasters) can predispose to injury in some children and adolescents with preexisting medical conditions.
- Among the conditions that are considered contraindications to exposure to high g force or other thrill rides are Marfan syndrome, Down syndrome, hypermobility-related disorders, coagulation disorders, and many cardiac disorders, particularly ones with rhythm abnormalities.

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Title: Pediatric heat related car deaths

Category: Pediatrics

Keywords: hyperthermia, pediatrics, car (PubMed Search)

Posted: 8/20/2021 by Jenny Guyther, MD (Updated: 11/24/2024)
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- A higher metabolic rate, reduced capacity for sweating, greater thermolability, and a larger body surface-to-volume ratio make infants and young children more susceptible to hyperthermia.

- Temperatures can rise rapidly within enclosed vehicles, reaching maximum temperatures within 5 minutes. In an open area with an ambient temp of 98 F (36.8 C), interior temperatures reach 124-152 F (51 to 67 C) within 15 minutes of closing the car doors.

- Texas leads the country in the numbers of pediatric heatstroke fatalities due to unattended children left in cars, followed by Florida and California.

- Most heatstroke victims (78.2%) were unknowingly left in vehicles by their caregivers.

- Most organizations interested in child safety issues recommend placing a phone, briefcase, or handbag in the back seat when traveling with a child as one way to prevent heatstroke fatalities.

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Title: Does atropine prevent bradycardia during rapid sequence intubation in pediatric patients?

Category: Pediatrics

Keywords: Bradycardia, intubation, RSI, atropine (PubMed Search)

Posted: 7/16/2021 by Jenny Guyther, MD (Updated: 11/24/2024)
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Atropine has historically been used in the pediatric population as a premedication for rapid sequence intubation (RSI) in order to prevent bradycardia.   Recent research indicates that bradycardia that occurs during intubation may be driven by hypoxia as opposed to a vagal response. In 2002, the American Heart Association guidelines recommended pretreatment with atropine for all children younger than 1 year, children receiving succinylcholine, adolescents receiving a second dose of succinylcholine and anyone with bradycardia at the time of induction. The 2015 AHA Pediatric Advanced Life Support guidelines revised the statement on atropine to say that "it may be reasonable for practitioners to use atropine as a premedication in specific emergency intubations when there is higher risk of bradycardia." 
This study retrospectively looked at 62 patients who underwent rapid sequence intubation.  3 patients experienced a bradycardic event during intubation, 1 of which received atropine.  15 patients received atropine for pretreatment. The incidence of bradycardia was similar between those received atropine and those who did not.
Bottom line: Although atropine is generally considered safe, larger studies are needed to determine if there are any specific indications for atropine as a premedication in RSI or if atropine is needed at all for the prevention of bradycardia.

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Title: Treatment of fingernail avulsion injuries

Category: Pediatrics

Keywords: finger injuries, nail bed (PubMed Search)

Posted: 6/18/2021 by Jenny Guyther, MD (Updated: 11/24/2024)
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Traditional management (referred to as "operative management") of a nail avulsion is to replace the nail in the epicanthal fold and suture this in place.  A study was done to see if wound cleaning and placement of a non-adhesive dressing was non inferior to this traditional management.  The primary outcome was the appearance of the new nail at 6 months as determined by 2 separate physicians using a Nail Appearance Score (NAS) and who were blinded to the treatment groups.  The secondary outcomes were patient and parental satisfaction and infection rate.  There were no statistically significant differences in the NAS or patient and parental satisfaction scores between the 2 groups.
Parents were informed of both options and allowed to choose between the treatments.  Patients between 1-16 years with proximal or complete nail bed avulsion injuries were included.
Conclusions: In this small study, non-operative management for fingernail avulsions was not inferior to operative management.

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