Texas — Targeted Issue

Author(s)/Presenter(s)

Marino, M. C., D. G. Ostermayer, J. A. Mondragon, E. A. Camp, E. M. Keating, L. B. Fornage, C. A. Brown and M. I. Shah

Abstract/Description

Background: Seizures and anaphylaxis are life-threatening conditions that require immediate treatment in the prehospital setting. There is variation in treatment of pediatric prehospital patients for both anaphylaxis and seizures. This educational study was done to improve compliance with pediatric prehospital protocols, educate prehospital providers and decrease variation in care.

Objective: To improve the quality of care for children with seizures and anaphylaxis in the prehospital setting using a bundled, multifaceted educational intervention.

Methods: Evidence-based pediatric prehospital guidelines for seizures and anaphylaxis were used to create a curriculum for the paramedics in the EMS system. The curriculum included in-person training, videos, distribution of decision support tools, and a targeted social media campaign to reinforce the evidence-based guidelines. Prehospital charts were reviewed for pediatric patients with a chief complaint of anaphylaxis or seizures who were transported by paramedics to one of ten hospitals, including three children's hospitals, for 8 months prior to the intervention and eight months following the intervention. The primary outcome for seizures was whether midazolam was given via the preferred intranasal (IN) or intramuscular (IM) routes. The primary outcome for anaphylaxis was whether IM epinephrine was given.

Results: A total of 1,402 pediatric patients were transported for seizures by paramedics to during the study period. A total of 88 patients were actively seizing pre-intervention and 93 post-intervention. Of the actively seizing patients, 52 were given midazolam pre-intervention and 62 were given midazolam post-intervention. Pre-intervention, 29% (15/52) of the seizing patients received midazolam via the preferred IM or IN routes, compared to 74% (46/62) of the seizing patients post-intervention. A total of 45 patients with anaphylaxis were transported by paramedics, 30 pre-intervention and 15 post-intervention. Paramedics administered epinephrine to 17% (5/30) patients pre-intervention and 67% (10/15) patients post-intervention.

Conclusion: The use of a bundled, multifaceted educational intervention including in-person training, decision support tools, and social media improved adherence to updated evidence-based pediatric prehospital protocols.

Author(s)/Presenter(s)

Nicolaus W Glomb, Manish I Shah, Andrea T Cruz

Abstract/Description

Background: There is global variation in the ability of hospital-based emergency centres to provide paediatric emergency medicine (PEM) services. Although minimum standards have been proposed, they may not be applicable in resource-limited settings.

Objective: The goal was to identify reasonable minimum standards to provide safe and effective care for acutely ill children in resource-limited settings.

Methods: Using previously proposed standards from the International Federation of Emergency Medicine (IFEM), a modified Delphi approach was used to reach agreement regarding minimum standards for PEM in resource-limited settings. Three rounds of surveys were electronically distributed to physicians working in resource-limited settings. Those standards with >67% agreement advanced to the subsequent round.

Results: The categories of the surviving criteria included integrated service design, child and family-friendly care, initial assessment of the ill child, stabilising and treating an ill child, staff training and competence, equipment, supplies and medications, quality and safety, child protection, and advanced training and academic research.

Conclusions: Experts with experience in acute care of children in resource-limited settings have prioritised standards for paediatric emergency care. They identified 26 variables in nine domains from the original IFEM list of standards and two additional free text standards for the care of acutely ill children. This list may serve as a helpful guide for emergency centres to provide medical treatment for acutely ill children in resource-limited settings.

Author(s)/Presenter(s)

E Brooke Lerner, Amy Drendel, Richard Falcone Jr, Keith Weitze, Mohamed K Badawy, Arthur Cooper, Jeremy Cushman, Patrick Drayna, David Gourlay, Matthew Gray, Manish Shah

Abstract/Description

BACKGROUND: Verbal prehospital reports on an injured patient’s condition are typically used by trauma centers to determine if a trauma team should be present in the emergency department prior to patient arrival (i.e., trauma team activation). Efficacy studies of trauma team activation protocols cannot be conducted without a criterion standard definition for which pediatric patients need a trauma team activation.

OBJECTIVE: To develop a consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation.

METHODS: Ten local and national experts in emergency medicine, emergency medical services, and trauma were recruited to participate in a Modified Delphi survey process. The initial survey was populated based on outcomes that had been used in previously published literature on trauma team activation. The criterion standard definition for trauma team activation was refined iteratively based on survey responses until at least 80% agreement was achieved for each criterion.

RESULTS: After five voting rounds a consensus-based definition for pediatric trauma team activation was developed. Twelve criteria were identified along with a corresponding time interval in which each criterion had to occur. The criteria include receiving specific surgery types, interventional radiology, advanced airway management, thoracostomy, blood products, spinal injury, emergency cesarean section, vasopressors, burr hole or other procedure to relieve intracranial pressure, pericardiocentesis, thoracotomy, and death in the emergency department. All expert panel members voted in all 5 voting rounds, except 1 member missed rounds 1 and 2. Each criterion had greater than 80% agreement from the panel.

CONCLUSION: A criterion standard definition for the highest-level pediatric trauma team activation was developed. This criterion standard definition will advance trauma research by allowing investigators to determine the accuracy and effectiveness of highest-level pediatric trauma team activation protocols.

Author(s)/Presenter(s)

Manish I Shah, John M Carey, Sarah E Rapp, Marina Masciale, Wendy B Alcanter, Juan A Mondragon, Elizabeth A Camp, Samuel J Prater, Cara B Doughty

Abstract/Description

Background: A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training.

Objectives: The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs).

Methods: This is a two-year retrospective cohort study of paramedics who transported 0-18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearson's χ(2) test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous).

Results: Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72-2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77-2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study.

Conclusion: Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence.

Keywords

seizure; emergency medical services; simulation; pediatrics

Author(s)/Presenter(s)

Kathleen Adelgais, MD, MPH, Toni Gross, MD, MPH, Manish Shah, MD, Lara Rappaport, MD, MPH

Abstract/Description

Purpose: Recently developed pediatric prehospital evidence-based guidelines (EBG) provide important recommendations for prehospital management of children. The Equipment List for Ground Ambulances recommends the use of the pediatric length-based tape. The Broselow™ Pediatric Emergency Tape (Broselow LBT) has assessment tools, equipment selection, and medication doses, however its ability to support recommendations per these EBGs is unknown. The purpose of this study was to examine the ability of the Broselow LBT to facilitate care per pediatric prehospital EBGs.
Methods: We identified specific recommendations related to assessment tools, equipment, and medication dosages from 7 pediatric prehospital EBGs: anaphylaxis, respiratory distress, airway management, shock (medical and traumatic), traumatic pain, and seizure management. We excluded recommendations requiring equipment or medications for which there is no generally accepted pediatric dose or size. Recommendations were stratified by type of recommendation; medication or equipment with assessment tools categorized as equipment. Three study investigators examined the Broselow LBT (2011, Edition A) using a standardized scoring sheet to classify each recommendation: “CAN be followed” (stratified by correct and incorrect information), and “CAN NOT be followed” (no information). Investigators utilized a modified Delphi iteration with a target for consensus of >95%. The primary outcome was the number of recommendations for which Broselow LBT provided correct information stratified by type of recommendation (medication vs. equipment).
Results: The 7 EBGs contain a total of 42 separate recommendations with 10 pertaining to more than one EBG. Target consensus for classifying recommendations was achieved after 2 iterations. Overall, 28 of 42 recommendations (57%) could be correctly followed on the Broselow LBT. For recommendations related to equipment, 75% could be correctly followed with only 4 items missing (GCS information, pain scale, pediatric VS norms, and thoracostomy needle size). All recommendations on the airway management EBG were related to equipment and the majority (8/9) could be correctly followed. For recommendations related to medication, only 4/26 (15%) could be correctly followed (normal saline bolus, lorazepam dose, glucagon, and dextrose). For 14/26 (54%) medication related recommendations (bronchodilators, steroids, various vasopressors, morphine, and histamine blockade), there was no information on the Broselow LBT. Information was incorrect medication for the remaining 8 (31%) medication related recommendations including dose and/or route for fentanyl, midazolam, 1:1000 epinephrine, magnesium sulfate, antibiotics, and isotonic fluid volume for cardiogenic shock. Incorrect medication information for 1:1000 epinephrine affects 4 recommendations across 2 EBGs (respiratory distress and anaphylaxis) and lack of information for an intranasal dosing affects 2 additional EBGs (seizure and traumatic pain).
Conclusion: The Broselow LBT provides sufficient information for management per pediatric prehospital EBG recommendations primarily related to equipment with significant limitations for those recommendations related to medication administration. Additional tools may be necessary to facilitate pediatric care according to prehospital EBG recommendations.

Author(s)/Presenter(s)

Manish Shah