Plenary Presentations
A multicenter randomized controlled trial of nebulized epinephrine and dexamethasone in outpatients with bronchiolitis
Plint AC, Johnson DW, Patel H, Wiebe N, Correll R, Brant R, Mitton C, Gouin S, Bhatt M, Joubert G, Black K, Turner T, Whitehouse S, Klassen TP; the Pediatric Emergency Research Canada (PERC). Departments of Pediatrics and Emergency Medicine, University of Ottawa, Ottawa, ON
Introduction: Bronchiolitis is the most common disease of the lower respiratory tract in the first year of life. Hospital admissions have almost doubled over the last 10–15 years in North America. The objective of this study was to determine if the treatment of infants with bronchiolitis presenting to the emergency department (ED) with nebulized epinephrine (epi), oral dexamethasone (dex) or both results in a reduction in hospital admissions.
Methods: Infants, 6 weeks to 12 months, presenting with bronchiolitis to 8 Canadian pediatric EDs were enrolled in a double-blind, placebo-controlled 2-factor RCT. Infants were randomized to treatment with 1) epi and dex, 2) epi plus placebo, 3) nebulized placebo plus dex and 4) nebulized placebo plus oral placebo. The primary outcome measure was hospital admission up to 7 days after enrolment.
Results: Eighthundred subjects were enrolled. Study groups were similarin age, sex, RSV status, baseline clinical score, length of symptoms and atopy history. The epi/dex groups were significantly less likely to be admitted by day 7 than the placebo group, but neither the dex nor epi alone groups showed any significant reduction in admission compared with placebo.
The number needed to treat with epi/dex to prevent 1 admission within 7 days of the initial visit is 11.4. The epi and epi/dex group showed a significant improvement in clinical score and heart rate over the first hour of the study when compared with placebo, while the dex group did not.
Conclusion: In this largest RCT of bronchiolitis treatment, neither dex nor epi alone lowered hospitalization rates, but combined therapy with epinephrine and dexamethasone reduced hospital admissions by 30%. Eleven infants would need to be treated with this combination to prevent 1 hospitalization
Isolated recurrent vomiting rarely predicts brain injury in children with blunt minor head injury
Osmond MH, Klassen TP, Stiell IG, Correll R; the CATCH Study Group. Department of Pediatrics, University of Ottawa, Ottawa, ON
Introduction: Recurrent vomiting is a frequent indication for ordering a cranial CT scan in children with head injury. It is unknown whether isolated recurrent vomiting is predictive of traumatic brain injury (TBI) in children with minor head injury.
Methods: We carried out this prospective cohort study in 10 Canadian pediatric teaching hospital EDs and enrolled consecutive children (0–16 yr) who presented with blunt head trauma, a Glasgow Coma Scale (GCS) score of 13–15 and documented loss of consciousness, amnesia, disorientation, recurrent vomiting (2 distinct episodes at least 15 min apart) or irritability. We evaluated the association of recurrent vomiting with TBI seen by CT in those patients with no other signs or symptoms of brain injury (isolated vomiting).
Results: Of the 3867 children with minor head injury, 161 (4.2%) had TBI on CT and 24 (0.6%) required neurological intervention. Of the 1634 (42.3%) children who had recurrent vomiting, 89 (5.4%, 95% CI 4.4%–6.7%) had TBI on CT versus 72 of 2233 (3.2%, 95% CI 2.6%–4.0%) without recurrent vomiting (difference 2.2%, 95% CI 0.09%–3.6%). Neurological intervention occurred in 16 of 1634 (1.0%, 95%CI 0.6%–1.6%) children with recurrent vomiting. 226 out of 3867 (5.8%) children had isolated recurrent vomiting (mean age 2.6, SD 2.0, 72.1% ≤ 3 yr). Compared with all enrolled children, those with isolated recurrent vomiting were younger (mean age 2.6 v. 9.6 yr, p < 0.001). For those with isolated recurrent vomiting (i.e., without any other symptoms or signs of brain injury), 2 of 226 (0.9%, 95% CI 0.2%–3.2%) had TBI on CT and none (95% CI 0.0%–1.7%) had brain injury that required neurological intervention.
Conclusion: Isolated recurrent vomiting following blunt head injury occurs more commonly in young children and is rarely predictive of TBI on CT or brain injury requiring neurological intervention. Cranial CT scans should be decreased in this population as they are rarely positive for TBI.
Oral Presentations
Estimating physician workload in the pediatric emergency department
Millar KR, Tough S, Stewart B, Nijssen-Jordan C. Alberta Children’s Hospital, Calgary, AB
Introduction: The factors which contribute to emergency department (ED) physician workload are complex and likely vary from one ED setting to another. Studies designed to quantify ED physician workload have been sparse and have focused on general ED settings. The goal of this study was to develop a model which included demographic and clinical variables that would enable the prediction of physician time needed to treat patients in the pediatric ED.
Methods:Pediatric ED physician shifts were shadowed and data was collected on 205 patient visits. Data collected included patient variables and physician time spent on patient care, educational and administrative activities. Multivariate regression was used to determine which variables had the strongest influence on physician time needed to treat patients. For model derivation, physician time was defined as the sum of direct and indirect patient care for each patient.
Results:Physicians spent 80% of their time on patient care and 20% on educational and administrative tasks. The variables which were most strongly predictive of physician time needed to treat patients in a pediatric ED were CTAS score, arrival by ambulance, performance of a procedure by a physician, performance of a laboratory test and need for admission. Employing these 5 key variables in a regression model enabled the prediction of 40% of the variance in physician time needed to treat patients. The derived multivariate model was LN (physician time) = 3.6095 – 0.3694 (CTAS) + 0.3353(arrival by ambulance) + 0.3300 (procedure) + 0.7584 (laboratory) + 0.4083 (admitted) + 0.4075 (CTAS × laboratory). Patient age, trainee involvement, language barrier, referral by another physician and need for radiographs were not found to influence physician time needed to treat patients.
Conclusion: The model derived in this study could be used for pediatric ED man power planning, derivation of equitable funding formulas for pediatric ED physicians and physician performance evaluation.
Interrater agreement between nurses using a computerized version of the Paediatric Canadian Triage and Acuity Scale in a PED
Gravel J, Gouin S, Manzano S, Arsenault M, Amre D. CHU Sainte- Justine, Montréal, QC
Introduction: The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) is a 5-level triage tool constructed from a consensus of experts. Until now, there has been no evaluation of the reliability of the tool for children presenting to emergency departments (ED) in a clinical context. Objective: To measure the interrater agreement for nurses who assigned triage levels to children visiting a pediatric ED using a computerized version of the PaedCTAS (Staturg from Statdev).
Methods: This was a prospective cohort study evaluating all children (0–18 yr old) initially triaged from level II (emergent) to V (non urgent) on the PaedCTAS. Recruitment occurred on a convenience sample of patients triaged during 40 shifts from June to September 2007 in a tertiary care pediatric ED. All patients were initially triaged by a regular triage nurse using a computerized version of the PaedCTAS (Staturg). Those not requiring immediate care were eligible to participate. Research nurses recruited eligible patients immediately after their first triage to perform a second triage (within 15 min) using the same triage tool. Both triages were performed blinded to each other. The research nurses were regular ED nurses performing extra hours for research. The primary outcome measure was the interrater agreement between the two nurses measured by the quadratic weighted κ score.
Results: There were 499 patients recruited to participate in the study and they were all evaluated by 2 nurses. The overall interrater agreement between the nurses was good as demonstrated by a quadratic weighted κ score of 0.61 (95% CI 0.52–0.69). There was a discrepancy of more than 1 level in only 10 patients (0.02).
Conclusion: The Staturg tool is a computerized version of the PaedCTAS that demonstrates good interrater agreement between nurses assigning triage level to children presenting to a pediatric ED.
Validity of a computerized version of the Paediatric Canadian Triage and Acuity Scale
Gravel J, Manzano S, Arsenault M. CHU Sainte-Justine, Montréal, QC
Background: The Paediatric Canadian Triage and Acuity Scale (PaedCTAS) is a 5-level triage tool for the emergency department (ED). Staturg (from Statdev, Montréal) is a computerized version of the PaedCTAS. Objective: Evaluate the validity of a computerized version of the PaedCTAS (Staturg) for children visiting a pediatric ED.
Methods: This was a retrospective cohort study evaluating all children presenting to a pediatric university-affiliated ED for a 1-year period. Data were retrieved from the ED computerized database. Information regarding triage and disposition was prospectively registered by a clerk in the ED database during patients’ management. In the absence of a gold standard for triage, hospitalization, admission to pediatric intensive care unit (PICU), length of stay (LOS) in the ED and patients that left without being seen by a physician (LWBS) were used as surrogate markers of severity. The primary outcome measure was the correlation between triage level (from I to V) and hospitalization. It was estimated that the evaluation of all patients visiting the ED for 1 year would provide more than 500 patients in each triage level.
Results:From Nov. 11, 2006, to Nov. 10, 2007, 58 569 patients were triaged in the ED. Hospitalization proportion was 63% for resuscitation (level I), 37% for emergent, 14% for urgent, 2% for semi urgent and 1% for nonurgent. There was also a good correlation between triage levels and admission to PICU, LOS and proportion of LWBS.
Conclusion: Staturg is a computerized version of the PaedCTAS that shows good ability to predict hospitalization, admission to PICU, LOS in the ED and proportion of patient that left without being seen by a physician. These results suggest that Paed- CTAS has a good validity for triage of children in a pediatric ED
Prospective evaluation of a revised preschool respiratory assessment measure in children with acute asthma
Gouin S, Gravel J, Guimont C, Amre D. Division of Emergency Medicine and Research Institute of CHU Sainte-Justine, CHUQ pavillon of CHUL, Université de Montréal and Laval, Montréal and Québec City, QC
Introduction: Adequate evaluation of the severity of asthma exacerbations is important. A promising clinical severity score is the Preschool Respiratory Assessment Measure (PRAM); however, it was described as cumbersome to use. The aim of our study is to compare the accuracy and responsiveness of the PRAM (5 variables) and a revised PRAM (rPRAM) (4 variables) during an asthma exacerbation in children.
Methods: A prospective cohort study was conducted in an academic pediatric ED from February 2006 to October 2007. All patients between the ages of 18 months to 7 years who presented to the ED for an asthma exacerbation while one of the research assistants was available were approached. The outcomes of interest were the length of stay greater than 6 hours in the ED or admission and the physicians’ judgment of severity. Clinical findings were assessed by respiratory therapists at the start of the visit and after 90 minutes of treatment.
Results: During the study period, 3788 patients were seen in the ED for an asthma exacerbation. Of these patients, 291 were approached and 8 refused to participate. The mean age was 3.4 years (SD 1.5) and 63.6% were boys. There was a high correlation between the physicians judgment of severity and PRAM (r = 0.45) and rPRAM (r = 0.42). PRAM and rPRAM were moderate predictors of length of stay greater than 6 hours (AUC= 0.67 and 0.64, respectively) but better predictors of admission (AUC = 0.85 and 0.80, respectively) when calculated at the start of the ED visit. When the scores were recalculated after 90 minutes of treatment, the predictive abilities for length of stay greater than 6 hours and admission were higher for both PRAM (AUC = 0.77 and 0.90) and rPRAM (AUC = 0.75 and 0.90). The scores were shown to be responsive, with a 50% relative improvement in score from start to 90 minutes of treatment for both the PRAM and rPRAM.
Conclusion: The rPRAM, which is a simplified version of the PRAM, is a valid measure of asthma severity in children and shows similar discriminative and responsive properties.
Prospective validation of the Ottawa Ankle Rule and the Malleolar Zones Algorithm for children with ankle trauma
Hedrei P, Gravel J, Gouin S, Grimard G. CHU Sainte-Justine, Montréal, QC
Introduction: The Ottawa Ankle Rule (OAR) and the Malleolar Zone Algorithm (MZA) have been developed to identify children needing a radiography following an ankle trauma. Objective: To determine the criterion validity of the 2 rules for predicting significant ankle fractures in children.
Methods: This was a prospective cohort study performed in a university-affiliated pediatric emergency department (ED). Children younger than 16 years suffering from an acute ankle trauma were eligible. A priori, physicians were instructed in how to assess patients according to the rules. The ED physician implemented each rule with the aid of a standardized diagram. Ankle radiography and referral to orthopedics were left at the physicians’ discretion. Final diagnosis was made at follow-up at the orthopedic clinic. A phone follow-up was made for those who needed no orthopedics follow-up. All fractures other than a nondisplaced Salter I fracture of the fibula were considered significant. The primary outcome was the presence of a significant fracture as confirmed in the orthopedic follow-up. The criterion validity was calculated for each rule.
Results: Radiography was performed in 245 (90%) of the 272 participants. All patients with no radiograph were reached by phone. Eighty patients had an ankle fracture including 33 with a Salter I fracture of the fibula and 47 with a significant fracture. The sensitivity and specificity for a significant fracture were 1.00 (95% CI 0.94–1.00) and 0.27 (95% CI 0.24–0.30) for the OAR, and 0.87 (95% CI 0.84–1.00) and 0.24 (95% CI 0.21–0.27) for the MZA.
Conclusion: The OAR identified all children with a significant fracture, whereas the MZA showed a lower sensitivity. The use of the OAR would decrease by 10% the number of requested ankle radiography in our setting whereas the use of the MZA would not decrease it.
Ottawa Ankle Rules to exclude fractures in the pediatric population: a systematic review and meta-analysis
Dowling SK, Spooner C, Liang Y, Dryden DM, Friesen C, Klassen TP, Wright RB. University of Calgary, Calgary, AB; Alberta Research Centre for Child Health Evidence, Department of Pediatrics, University of Alberta, Edmonton, AB
Introduction: Although the role of the Ottawa Ankle Rules (OAR) is routinely accepted in adults, the accuracy of the OAR in children is less well established. The primary objective of this report was to conduct a quantitative systematic review to determine the diagnostic accuracy of the OAR to exclude fractures of the ankle and midfoot in children.
Methods: We searched electronic databases (i.e. MEDLINE, EMBASE and CINAHL) for published and gray literature and hand searched reference lists. Two reviewers independently applied inclusion/exclusion criteria (children [< 18 yr] presenting to the ED with an acute blunt ankle or midfoot injury, x-ray or proxy measure to confirm/exclude a fracture and sufficient data to create a 2 × 2 table). Data were extracted by one reviewer using a standard form and verified by a second reviewer. The data was then pooled using an approximation of the inverse variance approach; 95% confidence intervals were calculated using the exact method.
Results: We included 12 studies, which enrolled 3226 patients with 552 fractures (prevalence 17.1%). The pooled sensitivity was 98.2% (95% CI 96.7–99.1) and specificity was 29.5% (95% CI 27.8–31.3). The pooled negative and positive predictive value were 98.8% (95% CI 97.7–99.4) and 22.3% (95% CI 20.7–24.1), respectively. Of the 10 missed fractures, only 4 were characterized; 1 was a Salter-Harris (SH) I fracture, 1 was a SH-IV fracture and 2o were insignificant (either SH-I or avulsion fractures < 3 mm). Pooled estimate for x-ray reduction rates was 24.8% (95% CI 23.3–26.3). There was evidence of funnel plot asymmetry (p = 0.002), suggesting that there may be missing studies with smaller sample sizes but more significant results.
Conclusion: Based on the findings from our study, the OAR appears to be a reliable tool to exclude fractures in children presenting with ankle and midfoot injuries. The usage of the OAR in children would significantly decrease radiography usage with a very low likelihood of missing a fracture.
Passive versus active distraction for intravenous catheterization in the pediatric emergency department
Goldman RD, Koller D, Wan T, Bever S, Stuart S. PRETx Program, Division of Pediatric Emergency Medicine, BC Childrens Hospital, Department of Pediatrics, University of British Columbia, Vancouver, BC; Child Life Program, The Hospital for Sick Children, Department of Pediatrics, University of Toronto, Toronto, ON
Introduction: Children visiting the ED experience anxiety and pain during procedures. In order to ameliorate the effects of pain and anxiety, many hospitals have Child Life Specialist programs. The objective of this study was to compare the efficacy of active versus passive forms of distraction in decreasing anxiety and pain in children 5–18 years old undergoing IV insertion, the most common procedure in the pediatric ED.
Methods: This was a prospective, randomized trial comparing anxiety and pain response among children being active (experimental) or passive (control) during intravenous catheter insertion in the ED and while being supported by a Child Life Specialist. Outcome measures were recorded by a research assistant (RA) and included Observational Scale of Behavioral distress- Revised (OSBD-r) at baseline, immediately before IV insertion( s), immediately after IV insertion attempt(s) and every 2 minutes in between. The RA also recorded the Faces Pain Scale- Revised (FPS-r) for each angiocath insertion attempt. The number of IV attempts and the length of the procedure were also recorded.
Results: A total of 79 (89%) children completed the study. Children were 10 (SD 3) years old (range 5–18). Thirty-nine and 40 were randomized to the active and passive groups, respectively. Ten (13%) children that were allocated to the passive group were subsequently offered active forms of distraction to accommodate their perceived needs. There was no significant difference in mean OSBD-r and FPS-r between the groups. More children in the active group had a successful first attempt to insert an IV compared to the active group (89% v. 63%, respectively, p = 0.01) and the mean length of procedure was faster in the active group (1.2 v. 1.8 min, respectively, p = 0.02).
Conclusion: Active child participation in the distraction procedure by a Child Life Specialist during angiocath insertion appears to be more effective than passive forms of distraction, particularly as they relate to fewer attempts for successful cannulation. Keywords:distraction, IV catheter insertion, randomized trial.
DOES the Broselow Tape accurately estimate the weight of Canadian children?
Knight J, Lubell R, Milne WK. South Huron Hospital and University of Western Ontario, London, ON
Introduction: The Broselow Tape (BT) has been used for more than 20 years as a length-based estimate of body weight for children during resuscitation. Increasing childhood obesity has raised concern that the BT no longer accurately estimates weight. The purpose of this study was to validate the BT in Canadian children.
Methods: A convenient sample of children attending their community pediatrician’s office between October and December 2007 was used. Their actual weight was compared with their BT weight estimates using the Bland–Altman method. The correlation coefficient and percentage error (PE) was also calculated.
Results: A total of 499 children were included in the study. The mean age was 2.58 years (95% CI 2.31–2.85), mean height was 88.42 cm (95% CI 86.15–90.70), mean weight was 14.4 kg (95% CI 13.61–15.20) and mean BT weight was 13.31 kg (95% CI 12.62–14.00). Bland–Altman difference was 1.1 kg (–3.9 to 6.1). The correlation coefficient (r) was 0.9645 (p < 0.001, 95% CI 0.958–0.970). The BT had a PE > 10% one-third of the time and > 20% error 8.6% of the time.
Conclusion: The BT was often not accurate and tended to underestimates the weight of Canadian children.
