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Benefits of Strict Rest After Acute Concussion: A Randomized Controlled Trial.

Danny George Thomas, Jennifer N Apps, Raymond G Hoffmann, Michael McCrea, and Thomas Hammeke.

OBJECTIVES:To determine if recommending strict rest improved concussion recovery and outcome after discharge from the pediatric emergency department (ED).

METHODS:Patients aged 11 to 22 years presenting to a pediatric ED within 24 hours of concussion were recruited. Participants underwent neurocognitive, balance, and symptom assessment in the ED and were randomized to strict rest for 5 days versus usual care (1-2 days rest, followed by stepwise return to activity). Patients completed a diary used to record physical and mental activity level, calculate energy exertion, and record daily postconcussive symptoms. Neurocognitive and balance assessments were performed at 3 and 10 days postinjury. Sample size calculations were powered to detect clinically meaningful differences in postconcussive symptom, neurocognitive, and balance scores between treatment groups. Linear mixed modeling was used to detect contributions of group assignment to individual recovery trajectory.

RESULTS:Ninety-nine patients were enrolled; 88 completed all study procedures (45 intervention, 43 control). Postdischarge, both groups reported a 20% decrease in energy exertion and physical activity levels. As expected, the intervention group reported less school and after-school attendance for days 2 to 5 postconcussion (3.8 vs 6.7 hours total, P < .05). There was no clinically significant difference in neurocognitive or balance outcomes. However, the intervention group reported more daily postconcussive symptoms (total symptom score over 10 days, 187.9 vs 131.9, P < .03) and slower symptom resolution.

CONCLUSIONS:Recommending strict rest for adolescents immediately after concussion offered no added benefit over the usual care. Adolescents' symptom reporting was influenced by recommending strict rest.

Pediatrics, 2015.

https://foyer.swmed.edu/login?url=http://pediatrics.aappublications.org/cgi/doi/10.1542/peds.2014-0966

Pediatric overtriage as a consequence of the tachycardia responses of children upon ED admission.

Yu-Che Chang, Chip-Jin Ng, Chang-Teng Wu, Li-Chin Chen, Jih-Chang Chen, and Kuang-Hung Hsu.

BACKGROUND:Overtriage has been observed among pediatric patients in emergency departments (EDs) under 5-level acuity pediatric triage systems. This study aimed to investigate the causes of overtriage and to provide suggestions for future amendments to such systems.

METHODS:This study has a retrospective follow-up design in which 42000 pediatric patients who were admitted to the ED of the largest medical center in Taiwan between January and December of 2010 were recruited. The study variables included patient demographics, chief concerns, individual vital signs (ie, blood pressure, heart rate, body temperature, respiratory rate, and O2 saturation), triage level, ED final disposition, ED expenses, and total medical expenses. A logistic regression model was applied to explore the causes of overtriage and the effectiveness of a modified acuity system.

RESULTS:Approximately 13.6% of the pediatric ED visits were upgraded to acuity level 1 based on vital signs that included heart rate (97.3%). The strength of the trend association (odds ratio) between decreasing acuity urgency (from levels 1 to 5) and hospitalization increased from 0.73 (95% confidence interval, 0.72-0.75) with the Pediatric Triage and Acuity System (Ped-TTAS) to 0.57 (95% confidence interval, 0.55-0.59) with the modified Ped-TTAS, which downgraded acuity levels by excluding the weighting of vital signs. Further validation was accomplished by comparing the trend association between decreasing acuity urgency and total medical expenses (Ped-TTAS: = -0.13; modified Ped-TTAS: = -0.18).β β

CONCLUSIONS:Heart rate is prone to be affected by emotional responses among pediatric patients in certain specific age groups. Appropriate revisions of the pediatric triage system are suggested.

Am J Emerg Med, 2015 vol. 33 (1) pp. 1-6.

https://foyer.swmed.edu/login?url=http://eutils.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&id=25445860&retmode=ref&cmd=prlinks

Meta-analysis of the efficacy and safety of therapeutic hypothermia in children with acute traumatic brain injury.

Bin-Fei Zhang, Jiao Wang, Zun-Wei Liu, Yong-Lin Zhao, Dan-Dong Li, Ting-Qin Huang, Hua Gu, and Jin-Ning Song.

OBJECTIVE:To evaluate the therapeutic hypothermia on efficacy and safety of children with acute traumatic brain injury (TBI).

METHODS:Systematic literature retrieval was carried out to obtain studies of randomized controlled trials (RCTs) researching on therapeutic hypothermia for children with TBI before March 2014, from PubMed, Embase, Cochrane library, CNKI, WanFang, VIP, and CBM Databases. Data extraction and quality evaluation of RCTs were performed by 2 investigators independently. A meta-analysis was performed by RevMan 5.2.7.

RESULTS:Totally 7 RCTs with 442 children which 218 in hypothermia group and 224 in normothermia group were included. Meta-analysis showed therapeutic hypothermia could increase the fatality compared to normothermia group (RR=1.84, 95%CI: 1.15-2.93, P=0.01). Glasgow outcome scale (GOS) demonstrated 3m GOS 4-5 (RR=0.89, 95%CI: 0.68-1.16, P=0.39), 3m GOS 1-3 (RR=1.19, 95%CI: 0.80-1.76, P=0.39), 6m GOS 4-5 (RR=0.91, 95%CI: 0.78-1.07, P=0.26), 6m GOS 1-3 (RR=1.18, 95%CI: 0.88-1.59, P=0.27) did not differ between hypothermia group and normothermia group. Hypothermia did not increase the rate of pneumonia (RR=0.84, 95%CI: 0.63-1.12, P=0.23), or bleeding (RR=0.94, 95%CI: 0.39-2.26, P=0.89), but it might induce arrhythmias rated to hypothermia (RR=2.60, 95%CI: 1.06-6.41, P=0.04).

CONCLUSION:Children suffered TBI may not be able to benefit from therapeutic hypothermia, it may increase risk of fatality and arrhythmia. There is no evidence that therapeutic hypothermia improves prognosis of children with TBI, and no evidence that therapeutic hypothermia raise pneumonia and coagulation dysfunction. Limited by the quality of the included studies, the results need to be treated with caution. Further large-scale, well-designed RCTs on this topic are still needed.

World Neurosurg, 2014.


Prevalence and Predictors of Bacterial Meningitis in Young Infants with Fever without a Source.

Elena Martinez, Santiago Mintegi, Begoña Vilar, Maria Jesus Martinez, Amaia Lopez, Estibaliz Catediano, and Borja Gomez.

BACKGROUND::Classical criteria differ on when to perform cerebrospinal fluid (CSF) analysis in infants less than 90 days of age with fever without a source (FWS). Our objectives were to analyze the prevalence and microbiology of bacterial meningitis in this group and its prevalence in relation to clinical and laboratory risk factors.

METHODS::This is a sub-study of a prospective registry including all infants of this age with FWS seen between September 2003 and August 2013 in a Pediatric Emergency Department of a Tertiary Teaching Hospital.

RESULTS::Lumbar puncture was performed in 639 (27.0%) of the 2,362 infants with FWS seen, the rate being higher in not well-appearing infants (60.9% vs 25.7%; OR 4.49) and in those ≤21 days old (70.1% vs 20.4%; OR 9.14). Eleven infants were diagnosed with bacterial meningitis: nine were ≤21 days old (prevalence 2.8% vs 0.1%; OR 30.42) and five were not well-appearing (5.7% vs 0.2%; OR 23.06). Bacteria isolated were: S. agalactiae (3), E. coli (3), L. monocytogenes (3), S. pneumoniae (1) and N. meningitidis (1). None of the 1,975 well-appearing infants >21 days old was diagnosed with bacterial meningitis, regardless of whether biomarkers were altered.

CONCLUSIONS::In infants less than 90 days old with FWS, performing CSF analysis for ruling out bacterial meningitis must be strongly considered in not well-appearing infants and in those ≤21 days old. The recommendation of systematically performing CSF analysis in well-appearing infants 22-90 days of age on the basis of analytical criteria alone must be re-evaluated.

Pediatr Infect Dis J, 2014.


Newly Diagnosed Immune Thrombocytopenic Purpura in Childhood: Successful Implementation of a Limited Intervention Strategy in the Setting of Pediatric Emergency Care.

Barbara Rohmer, Frédéric V Valla, Frédéric Baleydier, Valérie Launay, Florence Dommange-Romero, and Corinne Pondarré.

Immune thrombocytopenic purpura is a bleeding disorder for which management remains mainly guided by platelet counts. Pediatric hematologists and emergency physicians collaborated to set up a limited intervention strategy, focusing on clinical bleeding severity irrespective of platelet counts, starting in the emergency room. We report how this strategy was safely applied for 106 consecutive children admitted for newly diagnosed immune thrombocytopenic purpura.

The Journal of Pediatrics, 2014.


Discussion:

Our study confirms that platelet count alone is not predictive for the individual risk of severe bleeds5,7-9; 64 of the 67 children with platelet count <10 G/L had minor or mild bleeding, and 3 out of the 6 patients presenting with moderate or severe hemorrhage had a platelet count >15 G/L.

Furthermore, in spite of the limited treatment strategy (93 out of the 106 total children and 61 out of 67 children with platelet count <10 G/L received either no therapy or a short course of prednisone), only one severe bleeding occurred, and it was at 8 months after diagnosis. This is in agreement with international data, showing that the occurrence of severe hemorrhage developing shortly after the diagnosis is infrequent,

even without platelet-enhancing therapy.5,9,10 For these reasons, we believe that the management of childhood ITP should focus on clinically important endpoints, mostly bleeding, rather than on surrogate endpoints such as platelet count.

Emergency bedside ultrasound for the diagnosis of pediatric intussusception: a retrospective review.

Samuel H F Lam, Adam Wise, and Christopher Yenter.

BACKGROUND:Ultrasound diagnosis of pediatric intussusception is feasible with limited operator training. The authors report the test characteristics of bedside ultrasound (BUS) for the diagnosis of pediatric intussusception at a single institution.

METHODS:Inclusion criteria were: 1) patients of 0-18 years old were seen in the pediatric emergency department (ED) with a clinical presentation suspicious for intussusception; 2) BUS was performed to identify intussusception and bedside impression documented in the medical record; 3) a "formal" diagnostic study (such as computed tomography, ultrasound, or barium enema) was performed by the radiology department after BUS was completed. Electronic medical record and ED BUS archive were screened for potentially eligible ED visits between January 1(st) 2009 to October 3(rd) 2012. These records were then reviewed to identify patients for inclusion in the study. All emergency physicians who performed the BUS had undergone a minimum of 1-hour didactic training on the use of BUS to diagnose pediatric intussusception.

RESULTS:A total of 1 631 charts were reviewed, with 49 meeting inclusion criteria. Five of those were later excluded for incomplete documentation or lack of saved BUS images. The prevalence of intussusception was 23%. The mean age of the subjects was 31 months. BUS was 100% sensitive (95%CI 66%-100%) and 94% specific (95%CI 79%-99%) for detection of pediatric intussusception compared to radiology study results. Positive and negative likelihood ratios were 16.5 (95%CI 4.30%-63.21%) and 0 (95%CI 0-0) respectively.

CONCLUSIONS: BUS is an accurate means of diagnosing acute intussusception in pediatric patients. Further study might be indicated to confirm such benefits.

World J Emerg Med, 2014 vol. 5 (4) pp. 255-258.


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