Abstract Direct oral anticoagulants have been used in the adult population for years and are being used more frequently in pediatrics. Direct oral anticoagulants are chosen preferentially because ...they do not require close outpatient monitoring, have an equal or better safety profile, and are easy for patients to take. Warfarin is the previous, more commonly used oral anticoagulant and acts as a vitamin K antagonist. Direct oral anticoagulants mechanism of action is different in that they directly inhibit part of the coagulation cascade accomplishing the same end goal. Given their differing mechanisms, they require alternate medications for proper reversal when concerned about overdose of life-threatening bleeds. This review will outline the most commonly used direct oral anticoagulants in pediatric populations and the supporting (mainly adult) data available for proper reversal of these medications in times of need.
Although most health care services can be provided in the medical home, children will be referred or require visits to the emergency department (ED) for a variety of conditions ranging from nonurgent ...to emergent. Continuation of medical care after discharge from an ED is dependent on parents or caregivers' understanding of follow-up instructions and adherence to medication administration recommendations. Barriers to obtaining medications after ED visits include lack of access because of pharmacy hours, affordability, and lack of understanding the importance of medication as part of treatment. ED visits often occur at times when community-based pharmacies are closed. Caregivers are typically concerned with getting their ill or injured child directly home once discharged from the ED. Approximately one-third of patients fail to obtain priority medications from a pharmacy after discharge from an ED. The option of judiciously dispensing medications at ED discharge from the outpatient pharmacy within the health care facility is a major convenience that helps to overcome this obstacle, improving the likelihood of medication adherence. Emergency care encounters should routinely be followed by visits to the primary care provider medical home to ensure complete and comprehensive care.
Patient handoffs at shift change in the emergency department (ED) are a well-known risk point for patient safety. Numerous methods have been implemented and studied to improve the quality of handoffs ...to mitigate this risk. However, few have investigated processes designed to decrease the number of handoffs. Our objective is to evaluate a novel attending physician staffing model in an academic pediatric ED that was designed to decrease patient handoffs.
A multidisciplinary team met in August 2012 to redesign the attending physician staffing model. The team sought to decrease patient handoffs, optimize provider efficiency, and balance workload without increasing total attending physician hours. The original model required multiple handoffs at shift change. This was replaced with overlapping “waterfall” shifts. This was a retrospective quality improvement study of a process change that evaluated the percentage of intradepartmental handoffs before and after implementation of a new novel attending physician staffing model. In addition, surveys were conducted among attending physicians and charge nurses to inquire about perceived impacts of the change.
A total of 43,835 patient encounters were analyzed. Immediately after implementation of the new model, there was a 25% reduction in the proportion of encounters with patient handoffs, from 7.9% to 5.9%. A survey of physicians and charge nurses demonstrated improved perceptions of patient safety, ED flow, and job satisfaction.
This new emergency physician staffing model with overlapping shifts decreased the proportion of patient handoffs. This innovative system can be implemented and scaled to suit EDs that have more than single-physician coverage.
There are 2 distinct age groups in which poisonings are most common: the toddler age group and the adolescent age group.1,2 Poisoned patients often present first to emergency departments, and ...emergency medicine practitioners need to be familiar with a range of common poisonings and with newly available substances.3 This issue of Clinical Pediatric Emergency Medicine will help clinicians to recognize and treat a variety of poisoned patients. The ingestion of potentially toxic amounts of caffeine in the forms of energy drinks, over-the-counter supplements, or anhydrous caffeine products places vulnerable children and adolescents at risk for accidental overdose. ...consultation with a regional poison control center (1 800 222 1222) may prove to be useful as a resource for up to date information and real time assistance when treating a poisoned patient. 1 J.B. Mowry, D.A. Spyker, D.E. Brooks, Clin Toxicol, Vol. 54, 2016, 924-1109 2 J.A. Lowry, J.S. Fine, D.P. Calello, S.M. Marcus, Pediatric fatality review of the 2013 National Poison Database System (NPDS): focus on intent, Clin Toxicol, Vol. 53, 2015, 79-81 3 A. Helander, M. Bäckberg, New psychoactive substances (NPS) - the Hydra monster of recreational drugs, Clin Toxicol, Vol. 55, 2017, 1-3
Introduction
A species of hawthorn,
Crataegus mexicana
(tejocote), has been marketed as a weight-loss supplement that is readily available for purchase online. While several hawthorn species have ...shown clinical benefit in the treatment of heart failure owing to their positive inotropic effects, little is known about hawthorn, and tejocote in particular, when consumed in excess. We describe a case of tejocote exposure from a weight-loss supplement resulting in severe cardiotoxicity.
Case Report
A healthy 16-year-old girl presented to an emergency department after ingesting eight pieces of her mother’s tejocote root weight-loss supplement. At arrival, she was drowsy, had active vomiting and diarrhea, and had a heart rate of 57 with normal respirations. Her initial blood chemistries were unremarkable, except for an elevated digoxin assay of 0.7 ng/mL (therapeutic range 0.5–2.0 ng/mL). All other drug screens were negative. She later developed severe bradycardia and multiple episodes of hypopnea that prompted a transfer to our institution, a tertiary pediatric hospital. Her ECG demonstrated a heart rate of 38 and Mobitz type 1 second-degree heart block. She was subsequently given two vials of Digoxin Immune Fab due to severe bradycardia in the setting of suspected digoxin-like cardiotoxicity after discussion with the regional poison control center. No clinical improvement was observed. Approximately 29 hours after ingestion, subsequent ECGs demonstrated a return to normal sinus rhythm, and her symptoms resolved.
Discussion
Tejocote root toxicity may cause dysrhythmias and respiratory depression. Similar to other species of hawthorn, tejocote root may cross-react with some commercial digoxin assays, resulting in a falsely elevated level.
Jimson weed is a poisonous plant containing tropane alkaloids that can cause anticholinergic toxicity. Recognition of anticholinergic toxidrome is important for prevention and management of ...potentially life-threatening complications of severe toxicity, including dysrhythmia and seizure.
Designed for pediatric emergency medicine (PEM) fellows, this simulation featured a 15-year-old female presenting to the emergency department (ED) with agitation and hallucinations. The team was required to perform a primary survey of the critically ill patient, recognize anticholinergic toxidrome from jimson weed intoxication, and treat complications of severe anticholinergic toxicity. Learners practiced critical resuscitation skills such as management of generalized tonic-clonic seizure, endotracheal intubation, synchronized cardioversion, and external cooling measures. A debriefing guide and participant evaluation forms were utilized. This simulation was created as both an in-person and a virtual simulation experience to accommodate COVID-19 social distancing guidelines.
Seventeen PEM fellows completed this simulation across three institutions (two in person, one virtual). Using 5-point Likert scales (with 5 being the most relevant or effective), participants rated the simulation as relevant to their work (
= 4.8,
= 0.5) as well as effective in teaching basic resuscitation skills (
= 4.7,
= 0.5), management of generalized tonic-clonic seizure (
= 4.8,
= 0.5), and treatment of ventricular tachycardia with appropriate interventions (
= 4.6,
= 0.5).
This simulation scenario allows pediatric medicine trainees in the ED to practice recognition and management of anticholinergic toxicity and its severe complications secondary to jimson weed ingestion.
OBJECTIVEStudies in pediatric patients with fever and neutropenia demonstrate that shorter time to antibiotics is associated with a decrease in pediatric intensive care unit admissions and ...in-hospital mortality. In 2012, a 2-phase quality improvement intervention was implemented in a pediatric emergency department (ED) to improve care for this high-risk patient population.The objective was to determine if the introduction of (1) a rapid absolute neutrophil count (ANC) test and (2) a standardized prearrival process decreased time to antibiotics for febrile hematology/oncology(heme/onc) patients presenting to the ED.
METHODSThe rapid ANC test introduced in February 2012 decreased turn-around-times in the laboratory from 60 to 10 minutes. The standardization of the prearrival communication between the heme/onc team and ED was implemented in August 2012 as part of a clinical standard work pathway for heme/onc patients who presented to the ED with fever and possible neutropenia. Time from arrival to the ED to administration of first antibiotic was measured.Data from January 2011 to December 2013 were analyzed using statistical process control.
RESULTSSeven hundred eighteen encounters for 327 patients were included. After the rapid ANC test, the proportion of patients who received antibiotics within 60 minutes of arrival increased from 47% to 60%. There was further improvement to 69% with implementation of the clinical standard work pathway. Mean time to antibiotics decreased from 83 to 65 minutes (21% decrease).
CONCLUSIONThis 2-phase quality improvement intervention increased the proportion of patients who received antibiotics within 60 minutes of arrival to the ED. Similar processes may be implemented in other pediatric EDs to improve timeliness of antibiotic administration.
The primary cause of death in patients with severe poisonings is cardiopulmonary failure. Meticulous supportive care remains the mainstay of treatment. However, early aggressive hemodynamic support ...with extracorporeal life support (ECLS) can be beneficial in patients with severe refractory toxin-induced shock. Although ECLS cannot neutralize toxins or facilitate poison removal, it can restore end-organ perfusion until elimination of the toxin and/or end-organ recovery occur. Preferentially, ECLS is used as a “bridge to recovery,” and as such, severe poisoning is perhaps one of the most ideal indications for its use. The aim of this article is to review the history of ECLS and provide an overview of basic physiologic principles, current techniques, indications, contraindications, complications, and its role in the treatment of the severely poisoned patient with refractory cardiovascular collapse.
Lidocaine is a common local anesthetic used during minor procedures performed on pediatric patients. A rare but toxic and life-threatening side effect of lidocaine is methemoglobinemia. It should be ...considered in children who are hypoxic after exposure to an oxidizing agent.
We developed this simulation case for pediatric emergency medicine (PEM) fellows, but it can be adapted for interprofessional simulation. The case involved a 1-month-old male with hypoxia and resulting central cyanosis after exposure to lidocaine. The team performed an initial evaluation and intervention, collected a history, and developed a differential diagnosis for hypoxia and central cyanosis in an infant. Methemoglobinemia was confirmed by CO-oximetry. Preparatory materials, a debriefing guide, and scenario evaluation forms assisted with facilitation.
Fifty-six participants (including 18 PEM fellows) completed this simulation across four institutions. Participants rated the scenario on a 5-point Likert scale (1 =
5 =
), finding it to be relevant to their work (median = 5) and realistic (median = 5). After participation in the simulation, learners felt confident in their ability to recognize methemoglobinemia (median = 4) and implement a plan to stabilize an infant with hypoxia (median = 4).
This simulation represents a resource for learners in the pediatric emergency department. It teaches the recognition and management of an infant with lidocaine toxicity and resultant methemoglobinemia. It uses experiential learning to teach and reinforce a systematic approach to the evaluation and management of a critically ill infant with acquired methemoglobinemia.
Serotonin syndrome is caused by an accumulation of serotonin in the body from drug interactions or overdose of serotonergic medications, including commonly used antidepressants. Symptoms can be ...life-threatening and encompass both neurologic and cardiovascular toxicity, including agitation, seizure, tachycardia, rhabdomyolysis, and hyperthermia.
This simulation case was developed for pediatric emergency medicine fellows and emergency medicine residents in the pediatric emergency department and can be altered to accommodate other learners. The case involved a 16-year-old male, represented by a low- or high-fidelity manikin, who presented with altered mental status/agitation after an overdose of antidepressant medication. The team of learners was required to perform a primary and a secondary assessment; manage airway, breathing, and circulation; and recognize and initiate treatment for serotonin syndrome. The patient had a seizure resulting in airway compromise requiring advanced airway support, as well as developed rhabdomyolysis requiring aggressive fluid hydration. We created a debriefing guide and a participant evaluation form.
Fifty-seven participants across five institutions completed this simulation, which included residents, fellows, faculty, and students. The scenario was rated by participants using a 5-point Likert scale and was generally well received. Participants rated the simulation case as effective in learning how to both recognize (
= 4.9) and manage (
= 4.8) serotonin syndrome.
This pediatric emergency simulation scenario can be tailored for a range of learner backgrounds and simulation environments. We used the participant evaluation form to improve future iterations of the simulation.
PDF
