Advanced prehospital care for pediatric emergencies

During an 18-month study period, the mobile intensive care unit (MICU) in Jerusalem responded to 307 pediatric emergencies, representing 5% of the total MICU case load. The most common medical problems were seizures, diagnosed in 100 cases (32%), and conditions related to trauma, diagnosed in 77 cases (23%). Forty-one cases (13%) were cardiac arrests. Nineteen patients were pronounced dead with a resuscitation attempt; resuscitation was attempted in 22 patients. Four patients were stabilized for admission to the hospital, but there were no long-term survivors. Eighteen cardiac arrest patients (82%) were found in asystole, and most had previous serious medical problems. Based on our experience children are less likely to require or benefit from advanced levels of prehospital care compared to the adult population. When resources for advanced care are limited, priority should be given to adult emergencies.     

A longitudinal study of residency-trained emergency physicians

An annual survey of emergency medicine (EM) graduate physicians from 31 programs was conducted from 1977 through 1979. Results of the 1979 data are presented. Practice patterns show that 96% of the EM graduates are providing patient care, and almost half are working in the states in which they trained. Of those caring for patients, 38.8% practice in an urban location and only 7% work in rural hospitals. Learning new skills and procedures and retaining skills are major problems faced by physicians in rural locations. Other activities of EM graduates include teaching medical students and residents, administration, research, and community emergency medical services. Data are analyzed with attention to long-term commitment to emergency medicine. Implications for manpower needs are suggested.     

An emergency medical services curriculum for emergency medicine residencies

Knowledge and experience in emergency medical services (EMS) are essential objectives for residency training in emergency medicine (EM). Although a need exists for competent physician EMS leaders, opportunities for educating emergency physicians in this aspect of emergency care have been few. We describe a curriculum for training EM residents in EMS. The purpose of this training is to assure competency in both on-line and off-line medical control. The former requires a working knowledge of the local system policies and the ability to respond appropriately to paramedic radio calls. Additional education prepares the resident for a much broader role in EMS, including off-line medical control.     

Impacto COVID-19 en la urgencia y hospitalización de un hospital terciario. Lecciones de gestión aprendidas

IntroductionThe objective is to analyze the impact of the COVID-19 pandemic on the pediatric emergencies and hospital admissions.MethodsRetrospective cohort study of patients treated in a tertiary hospital, from March 14 to April 26, 2020, compared to the same period of the previous 3 years.ResultsA notable overall reduction in emergency room visits and admissions is observed in all pediatric areas, maintaining care in neonatology and scheduled admissions in oncology.DiscussionThe reduction in global activity in pediatric emergencies is not only explained by the decrease in contagious diseases. The decrease in inadequate demand and inappropriate income may have contributed. The availability of pediatric beds would make the reduction of programmed surgical activity unnecessary and would allow the redistribution of resources to areas with greater healthcare pressure.     

A pediatric curriculum for emergency medicine training programs

Surveys of current training show that many areas of pediatric emergency medicine are not taught in emergency medicine residencies. Furthermore, published recommendations for minimum pediatric core content in emergency medicine are scant and conflicting. To address this issue we have compiled from a variety of sources a detailed pediatric emergencies curriculum for emergency residency training. This curriculum is complete, and yet may be carried out with currently available resources.     

突发公共卫生事件应急处置卫勤指挥协同模型构建研究

目的构建突发公共卫生事件应急处置卫勤指挥协同模型。方法以突发公共卫生事件应急处置卫勤指挥关键影响要素为基础,结合社会协同学"目标关联维度"理论,从时间维、空间维、基础维、保障维等4个维度入手,对突发公共卫生事件应急处置卫勤指挥主要内容开展研究,构建卫勤指挥协同模型。结果构建了突发公共卫生事件应急处置卫勤指挥协同模型,以提高卫勤指挥机关的组织指挥效率。     

Evidence for an informal clinical policy resulting in high use of a very-low-yield test

The actual and self-reported practice regarding the use of cerebrospinal fluid cultures for Mycobacterium tuberculosis was examined. All neurology house staff members surveyed, 62 percent of internal medicine house staff members, and none of pediatric house staff members reported that they would order mycobacterial cultures of cerebrospinal fluid routinely. The actual practice was comparable, with 71 percent of cerebrospinal fluid specimens being subjected to culture for mycobacteria on the neurology service, 65 percent on the internal medicine service, and 6 percent on the pediatric service. In this practice, medicine and neurology house staff differ significantly from their pediatric colleagues (p less than 0.001) and from the stated practice of their respective faculties (p less than 0.01). For at least six years, most medicine and neurology house staff have commonly applied an informal clinical policy of routinely culturing cerebrospinal fluid specimens for mycobacteria, despite a low suspicion of disease, lack of faculty support for the practice, and a zero yield for the test. Informal clinical policies such as this may be an important contributor to the problem of technology overuse.     

2009年四川省突发公共卫生事件网络直报质量分析

目的 对2009年四川省突发公共卫生事件网络直报质量进行分析,为进一步提高全省突发公共卫生事件报告质量提供科学依据.方法 利用《国家突发公共卫生事件管理信息系统》四川省2009年报告的突发公共卫生事件,以四川省2008年创建的突发公共卫生事件网络直报信息质量评价指标体系为研究方法,评价网络直报信息的准确性、及时性、完整性及事件处置的规范性等指标.结果 2009年四川省突发公共卫生事件网络直报信息系统共报告突发公共卫生事件103起,初始报告及时率为23.30％,进程报告及时率为61.51％,结案报告及时率40.20％,进程报告信息的完整率为95.23％,结案报告信息的完整率为86.41％,报告准确率达到90.00％以上,报告质量综合指数为0.8274.结论 2009年四川省突发公共卫生网络直报的总体质量较高,但及时率较低,应加强报告管理、队伍建设、培训,完善标准、规范管理,以进一步提高报告质量.     

A rapid method for estimating weight and resuscitation drug dosages from length in the pediatric age group

Drug dosages used during pediatric emergencies and resuscitation are often based on estimated body weight. The Broselow Tape, a tape measure that estimates weight and drug dosages for pediatric patients from their length, has been developed to facilitate proper dosing during emergencies. In our study, 937 children of known weight were measured with this tape. Weight estimates generated by the tape were found to be within 15% error for 79% of the children. The tape was found to be extremely accurate for children from 3.5 to 10 kg, and from 10 to 25 kg. Regression lines of estimated compared with actual weight for these children have slopes of 0.98 and 0.96, respectively, not significantly different from the ideal slope of 1.00 (P = 28 and .13). Accuracy was significantly decreased for measured children who weighed more than 25 kg. In a separate group of children (n = 53), the tape was shown to be more accurate than weight estimates made by residents and pediatric nurses (P less than .0001). Use of the Broselow Tape is a simple, accurate method of estimating pediatric weights and drug doses and eliminates the need for memorization and calculation.     

上海某医科院校突发公共卫生事件认知现况分析

目的调查并分析上海某医科院校大学生对突发公共卫生事件的认知情况及影响因素。方法采用随机抽样方法,2020年7月抽取上海某医科院校在校大学生508人开展问卷调查。结果大学生应急意识有提升空间,了解突发公共卫生事件程度不一,正确认知率有待提高;应急态度不积极,12.20%的学生态度消极;大学生应急知识和技能掌握情况不乐观,掌握程度低和基本掌握的高分人数高达44.98%,应急能力需加强并提高,20.47%的学生获取应急自救知识较被动。结论上海某医科院校大学生突发公共卫生事件认知水平有待提高,高校应尽可能增加实际演练次数,扩大应急知识宣讲范围及次数,全面提升大学生应急能力并丰富应急知识。     

Management of patients with hypertensive urgencies and emergencies: a systematic review of the literature

BACKGROUND: Hypertensive urgencies and emergencies are common clinical occurrences in hypertensive patients. Treatment practices vary considerably to because of the lack of evidence supporting the use of one therapeutic agent over another. This paper was designed to review the evidence for various pharmacotherapeutic regimens in the management of hypertensive urgencies and emergencies, in terms of the agents' abilities to reach predetermined "safe" goal blood pressures (BPs), and to prevent adverse events. METHODS: medline was searched from 1966 to 2001, and the reference lists of all the articles were retrieved and searched for relevant references, and experts in the field were contacted to identify other relevant studies. The Cochrane Library was also searched. Studies that were eligible for inclusion in this review were systematic reviews of randomized control trials (RCTs) and individual RCTs, all-or-none studies, systematic reviews of cohort studies and individual cohort studies, and outcomes research. No language restrictions were used. RESULTS: None of the trials included in this review identified an optimal rate of BP lowering in hypertensive emergencies and urgencies. The definitions of hypertensive emergencies and urgencies were not consistent, but emergencies always involved target end-organ damage, and urgencies were without such damage. Measures of outcome were not uniform between studies. The 4 hypertensive emergency and 15 hypertensive urgency studies represented 236 and 1,074 patients, respectively. The evidence indicated a nonsignificant trend toward increased efficacy with urapidil compared to nitroprusside for hypertensive emergencies (number needed to treat [NNT] for urapidil to achieve target BP, 12; 95% confidence interval [95% CI], number of patients needed to harm [NNH], 5 to NNT, 40 compared to nitroprusside). Several medications were efficacious in treating hypertensive urgencies, including: nicardipine (NNT for nicardipine compared to plabebo, 2 in one study [95% CI, 1 to 5] and 1 in another [95% CI, 1 to 1]); lacidipine (NNT, 2; 95% CI, 1 to 8 for lacidipine vs nifedipine) or urapidil (NNT for urapidil compared to enalaprilat and nifedipine, 4; 95% CI, 3 to 6); and nitroprusside and fenoldopam (all patients reached target BP in 2 studies). The studies reported 2 cases of cerebral ischemia secondary to nifedipine. CONCLUSIONS: Many effective agents exist for the treatment of hypertensive crises. Because of the lack of large randomized controlled trials, many questions remain unanswered, such as follow-up times and whether any of the studied agents have mortality benefit.     

新型冠状病毒肺炎疫情防控时期主动脉急症患者诊治的建议

近期新型冠状病毒肺炎(coronavirus disease 2019,COVID-19)疫情爆发,恰逢主动脉急症高发的冬春时节,而主动脉急症大多起病急骤,病情危重,死亡率高,需紧急处理。在国家"重大突发公共卫生事件一级响应机制"之下,疫期主动脉急症患者的诊疗需制订全新的流程。如何在这一特殊时期增强医护人员的防护和正确救治意识,既让主动脉急症患者获得及时、有效的治疗,又能避免救治期间可能发生的院内疫情传播,是急诊科、心外科、血管外科等相关学科当前面临的重大课题。本文呼吁各医疗单位在严格遵守政府和医院感控部门规章制度的基础上开展医疗实践,在"疫情防控为重,严防院内感染,确诊COVID-19患者首选保守"的前提下,提倡"择期手术适当推迟,限期手术术前隔离排查,急诊手术严格防护"的诊治原则,同时针对COVID-19疫期主动脉急症患者的急诊科接诊、病房收治、术前准备、术中防护、术后处理等方面提出了建议。     

Influence of ketamine versus fentanyl on pain relief for pediatric orthopedic emergencies: A meta-analysis of randomized controlled studies

Introduction:The comparison of ketamine with fentanyl for pain control of pediatric orthopedic emergencies remains controversial. We conduct a systematic review and meta-analysis to explore the influence of ketamine versus fentanyl on pain management among pediatric orthopedic emergencies.Methods:We have searched PubMed, EMbase, Web of science, EBSCO, and Cochrane library databases through September 2020 for randomized controlled trials assessing the effect of ketamine versus fentanyl on pain management for pediatric orthopedic emergencies.Results:Five randomized controlled trials are included in the meta-analysis. Overall, compared with fentanyl for pediatric orthopedic emergencies, ketamine led to similar change in pain scores at 15 to 20 minutes (standard mean difference = -0.05; 95% confidence interval [CI] = -0.38 to 0.28; P = .77) and 30 minutes (standard mean difference = 0.11; 95% CI = -0.20 to 0.42; P = .49), as well as rescue analgesia (RR = 0.90; 95% CI = 0.54 to 1.51; P = .69), but revealed the increase in nausea/vomiting (RR = 2.65; 95% CI = 1.13 to 6.18; P = .02) and dizziness (RR = 3.83; 95% CI = 1.38 to 10.60; P = .01).Conclusions:Ketamine may be similar to fentanyl in terms of the analgesic efficacy for pediatric orthopedic emergencies.     

Epidemiology of pediatric prehospital care

Very few studies about prehospital care of pediatric emergencies have been published. With new interest in emergency care of the pediatric population demonstrated by the development of Pediatric Advanced Life Support and Advanced Pediatric Life Support, it is imperative to have data that define the different types of problems encountered in the prehospital care setting and their outcomes. Prehospital assessment forms were reviewed retrospectively over a consecutive 12-month period beginning August 1, 1983. Patients under 19 years of age were studied in a service area with a population of 557,700. A total of 3,184 forms were analyzed, representing approximately 10% of all ambulance runs. This contrasts sharply with the fact that the pediatric age group represents 32% of the population. The major users were the youngest and the oldest of the pediatric population. Of the cases, 54.4% were in the trauma category. The largest trauma group was motor vehicle accidents in the adolescent age group. Male patients predominated in the trauma cases. Medical disorders were the major reason for prehospital care in the very young. The demand for emergency medical services (EMS) occurred mainly during the summer months and on weekends. More than 50 percent of all EMS pediatric cases occurred during the hours of 1:00 PM to 9:00 PM. Advanced life support was associated with prolonged on-scene time and had a relatively low use and success rate in the younger pediatric population. Resuscitation of 23 cases of pediatric prehospital arrest resulted in no survivors to hospital discharge. The appropriateness of prolonged time spent on scene (mean of 18.3 minutes in 1,196 cases) for prehospital pediatric emergencies requires further evaluation.     

关于传染病医院应对突发公共卫生事件的思考

传染病医院在应对突发公共卫生事件中的职能、任务明显得以拓展。本文阐述了传染病医院信息跟踪、监测预警、防治培训等8个方面的职能、任务,并提出了相应的综合能力建设10项措施。     

Health systems organization for emergency care

The increasing number of acute and severe digestive diseases presenting to hospital emergency departments, mainly related with an ageing population, demands an appropriate answer from health systems organization, taking into account the escalating pressure on cost reduction. However, patients expect and deserve a response that is appropriate, effective, efficient and safe. The huge variety of variables which can influence the evolution of such cases warranting intensive monitoring, and the coordination and optimization of a range of human and technical resources involved in the care of these high-risk patients, requires their admission in hospital units with conveniently equipped facilities, as is done for heart attack and stroke patients. Little information of gastroenterology emergencies as a function of structure, processes and outcome is available at the organizational level. Surveys that have been conducted in different countries just assess local treatment outcome and question the organizational structure and existing resources but its impact on the outcome is not clear. Most studies address the problem of upper gastrointestinal bleeding and the out-of-hours endoscopy services in the hospital setting. The demands placed on emergency (part of the overall continuum of care) are obvious, as are the needs for the efficient use of resources and processes to improve the quality of care, meaning data must cover the full care cycle. Gastrointestinal emergencies, namely gastrointestinal bleeding, must be incorporated into the overall emergency response as is done for heart attack and stroke. This chapter aims to provide a review of current literature/evidence on organizational health system models towards a better management of gastroenterology emergencies and proposes a research agenda.     

Pediatric mental health emergencies in the emergency medical services system. American College of Emergency Physicians

Emergency departments (EDs) are vital in the management of pediatric patients with mental health emergencies (MHE). Pediatric MHE are an increasing part of emergency medical practice because EDs have become the safety net for a fragmented mental health infrastructure which is experiencing critical shortages in services in all sectors. EDs must safely, humanely, and in a culturally and developmentally appropriate manner manage pediatric patients with undiagnosed and known mental illnesses including those with mental retardation, autistic spectrum disorders, attention deficit hyperactivity disorder (ADHD), and those experiencing a behavioral crisis. EDs also manage patients with suicidal ideation, depression, escalating aggression, substance abuse, post traumatic stress disorder, maltreatment, and those exposed to violence and unexpected deaths. EDs must address not only the physical but also the mental health needs of patients during and after mass casualty incidents and disasters. The American Academy of Pediatrics and the American College of Emergency Physicians support the following actions: advocacy for increased mental health resources, including improved pediatric mental health tools for the ED, increased mental health insurance coverage, adequate reimbursement at all levels; acknowledgment of the importance of the child's medical home, and promotion of education and research for mental health emergencies.     

Twenty-four-hour access to emergency care for children in managed care

Children's medical emergencies occur around the clock. In years past, the emergency department, open 24 hours a day, was a familiar site for treating these emergencies. However, in today's health care environment, the scenario can be more confusing. As many families move from a fee-for-service system into a managed care organization (MCO), they may be unclear about what they should do in an emergency involving their child. MCOs want to provide appropriate care, and at the same time, operate within a system designed to contain costs through the establishment of effective health care delivery systems. Providers of emergency services, including specialists in pediatric medicine and emergency medical services responders, also must contend with a different set of problems, including administrative entanglements and concerns about reimbursement for their services. This article continues the white paper series by the Emergency Medical Services for Children Managed Care Task Force.     

Ambulatory morning report

We assessed the ability of a novel ambulatory morning report format to expose internal medicine residents to the breadth of topics covered by the American Board of Internal Medicine (ABIM) exam. Cases were selected by the Ambulatory Assistant Chief Residents and recorded in a logbook to limit duplication. We conducted a retrospective review of 406 cases discussed from July 1998 to July 2000 and cataloged each according to the primary content area. The percentage of cases in each area accurately reflected that covered by the ABIM exam, with little redundancy or over-selection of esoteric diseases. Our data suggest that a general medicine clinic is capable of exposing house staff to the wide breadth of internal medicine topics previously thought to be unique to subspecialty clinics.     

Hypertensive emergencies in diabetic patients from predominantly African American urban communities

Aim: The aim of this study was to identify risk factors for hypertensive emergencies in diabetic patients presenting with severely elevated blood pressure.

Methods: Using electronic medical records, this study identified diabetic patients with hypertensive crisis who presented to the emergency department of Newark Beth Israel Medical Center, Newark, NJ from June 2013 to May 2016. Diabetic patients with hypertensive emergencies were compared with non-diabetic patients based on important demographic and clinical characteristics.

Results: Patients with diabetes accounted for 52.27% of all hypertensive emergencies during the study period. There were 264 diabetic patients with hypertensive emergencies and 519 diabetic patients with hypertensive urgencies. The majority of patients were African Americans (88.6%). The odds of hypertensive emergencies were strikingly higher in diabetic patients with hyperlipidemia (OR 1.66, 95% CI 1.23–2.24), coronary artery disease (OR 2.95, 95% CI 2.15–4.05), congestive heart failure (OR 6.28, 95% CI 4.49–8.80), renal insufficiency (OR 2.84, 95% CI 2.10–3.86) and low hemoglobin (OR 0.9, 95% CI 0.84–0.97). Acute or worsening heart failure was the most frequent acute target organ injury (49.6%) followed by non-ST elevation myocardial infarction (41.7%). Diabetic and non-diabetic patients had similar rates of target organ injuries.

Conclusion: The development of hypertensive emergencies in patients with diabetes was not because of diabetes per se but because of coexisting highly elevated blood pressure. Tight blood pressure control may decrease the risk of hypertensive emergencies in this patient population.