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Dupont A, Ciener D, Monteilh C, Bharath A, Thomas A, Wolpert K, Pearce J. Pediatric Emergency Medicine Didactics and Simulation (PEMDAS): Pediatric Sedation Complications. MedEdPORTAL 2024; 20:11384. [PMID: 38352651 PMCID: PMC10861802 DOI: 10.15766/mep_2374-8265.11384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/07/2023] [Accepted: 11/20/2023] [Indexed: 02/16/2024]
Abstract
Introduction Ketamine and propofol are commonly used agents for sedation in the pediatric emergency department (PED). While these medications routinely provide safe sedations, there are side effects providers should be able to recognize and manage. Currently, no pediatric sedation simulations exist in the literature. Methods We created two sedation simulation cases for learners, including pediatric emergency medicine (PEM) fellows, working in the PED: case 1, a 12-year-old male with a shoulder dislocation requiring reduction under propofol sedation, and case 2, a forearm fracture requiring reduction under ketamine sedation. Learner actions included setting up equipment for sedations, dosing medications correctly, and managing complications. Additionally, in case 2, learners assigned an American Society of Anesthesiologists classification and selected the appropriate candidate for PED sedation from amongst three patients. A debrief followed the cases. Next, a didactic presentation reinforced concepts discussed in the debrief. Participants then completed an evaluation of the simulation. Results Fifty-eight emergency medicine residents and PEM fellows across four sites at three institutions participated. Participants scored the simulations and the debriefing session on a 5-point Likert scale. Learners rated the scenario as clinically relevant (M = 4.37) and effective at improving their comfort level in caring for critically ill patients (M = 4.36). Learners felt the debrief provided valuable learning (M = 4.40) and was a safe learning environment (M = 4.50). Discussion These cases can be utilized as resources for learners in any emergency department and can be tailored to any training background of learner providing sedation.
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Affiliation(s)
- Amanda Dupont
- Assistant Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin
| | - Daisy Ciener
- Assistant Professor, Division of Emergency Medicine, Department of Pediatrics, Vanderbilt University Medical Center
| | - Cecilia Monteilh
- Assistant Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, Phoenix Children's
| | - Anita Bharath
- Assistant Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, Phoenix Children's
| | - Anita Thomas
- Associate Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, Seattle Children's
| | - Katherine Wolpert
- Assistant Professor, Section of Pediatric Emergency Medicine, Department of Pediatrics, Seattle Children's
| | - Jean Pearce
- Assistant Professor, Division of Pediatric Emergency Medicine, Department of Pediatrics, Medical College of Wisconsin
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Salevitz D, Lin CY, Alcanzo B, Namjoshi A, Lee P, Monteilh C, Grimsby G. Standardization of the management of pediatric urolithiasis in the emergency department. J Pediatr Urol 2024; 20:89.e1-89.e6. [PMID: 37919215 DOI: 10.1016/j.jpurol.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 10/11/2023] [Accepted: 10/13/2023] [Indexed: 11/04/2023]
Abstract
INTRODUCTION The incidence of urolithiasis in the pediatric population is rising and medical expulsive therapy (MET) using alpha-adrenergic antagonists has been found to be effective in aiding in the passage of ureteral stones in children. A prior review of patients presenting to our quaternary children's hospital with urolithiasis found only 54 % were prescribed MET and these patients had increased rates of spontaneous stone passage. Thus, an ED urolithiasis management protocol was created to standardize evaluation and care of children with suspected urolithiasis. OBJECTIVE To compare management of children with urolithiasis presenting to the ED before and after urolithiasis management protocol implementation. METHODS This is a retrospective review of patients with urolithiasis who presented to our children's ED from 2011 to 2022. The primary outcome was rate of MET prescribing before and after pathway implementation in July 2017, thus the pre-implementation group comprises patients who presented to the ED from July 2011 to July 2017, and the post-protocol group includes those who presented from August 2017 to April 2022. Secondary outcomes included CT utilization in the ED, surgical intervention rate, proportion with spontaneous stone passage, and frequency of urology consultation. Two-sample t-test and Fisher's exact test were used to compare the outcomes of interest before and after protocol implementation. RESULTS Of 337 patients who presented to the ED after protocol implementation, 120 met inclusion criteria. When comparing outcomes before and after implementation of the protocol, there was significantly decreased use of CT scans (79 % vs 50 %, p < 0.0001) and increased prescribing of MET (54 % vs 82 %, p < 0.0001). There was a significant decrease in opioids prescribed (44 % vs 26.7 %, p = 0.0040), and an increased rate of spontaneous stone passage (34 % vs 46 %, p = 0.0483). Lastly, there was a significant reduction in the rate of surgery for stone management after the implementation of protocol (35 % vs 17 %, p = 0.0020) DISCUSSION: As the ED is the primary site of presentation for many children with urolithiasis, standardization of evaluation and management provides an opportunity to improve outcomes in this population. We found that implementation of an ED urolithiasis management protocol was associated with decreased use of CT scans, decreased opioid prescribing, increased spontaneous stone passage, and decreased rate of surgical management for children with ureteral stones. CONCLUSIONS This study demonstrates the positive impact of standardizing care for children presenting to the ED with urolithiasis.
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Affiliation(s)
| | - Chung-Yon Lin
- University of Arizona, College of Medicine, Phoenix, United States
| | - Bernice Alcanzo
- University of Arizona, College of Medicine, Phoenix, United States
| | - Abhijeet Namjoshi
- Department of Pediatrics, Phoenix Children's Hospital, United States
| | - Philip Lee
- Department of Pediatrics, Phoenix Children's Hospital, United States
| | - Cecilia Monteilh
- Department of Emergency Medicine, Phoenix Children's Hospital, United States
| | - Gwen Grimsby
- Division of Urology, Phoenix Children's Hospital, United States.
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Tan YT, Shin CKJ, Park B, Bharath A, Wing R, Monteilh C, Sanseau E, Boswell B, Pearce JI, Luetje M, Enriquez B, Cicero M, Thomas A. Pediatric Emergency Medicine Didactics and Simulation: JumpSTART Secondary Triage for Mass Casualty Incidents. Cureus 2023; 15:e40009. [PMID: 37425609 PMCID: PMC10322648 DOI: 10.7759/cureus.40009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 06/01/2023] [Indexed: 07/11/2023] Open
Abstract
Mass casualty incidents (MCI), particularly involving pediatric patients, are high-risk, low-frequency occurrences that require exceptional emergency arrangements and advanced preparation. In the aftermath of an MCI, it is essential for medical personnel to accurately and promptly triage patients according to their acuity and urgency for care. As first responders bring patients from the field to the hospital, medical personnel are responsible for prompt secondary triage of these patients to appropriately delegate hospital resources. The JumpSTART triage algorithm (a variation of the Simple Triage and Rapid Treatment, or START, triage system) was originally designed for prehospital triage by prehospital providers but can also be used for secondary triage in the emergency department setting. This technical report describes a novel simulation-based curriculum for pediatric emergency medicine residents, fellows, and attendings involving the secondary triage of patients in the aftermath of an MCI in the emergency department. This curriculum highlights the importance of the JumpSTART triage algorithm and how to effectively implement it in the MCI setting.
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Affiliation(s)
- Yongtian Tina Tan
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
| | | | - Brian Park
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
| | - Anita Bharath
- Pediatric Emergency Medicine, University of Arizona College of Medicine, Phoenix, USA
| | - Robyn Wing
- Pediatric Emergency Medicine, Hasbro Children's Hospital, Providence, USA
| | - Cecilia Monteilh
- Pediatric Emergency Medicine, University of Arizona College of Medicine, Phoenix, USA
| | - Elizabeth Sanseau
- Pediatric Emergency Medicine, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Brittany Boswell
- Pediatric Emergency Medicine, Stanford University School of Medicine, Palo Alto, USA
| | - Jean I Pearce
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Maureen Luetje
- Pediatric Emergency Medicine, Medical College of Wisconsin, Milwaukee, USA
| | - Brianna Enriquez
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
| | - Mark Cicero
- Pediatric Emergency Medicine, Yale School of Medicine, New Haven, USA
| | - Anita Thomas
- Pediatric Emergency Medicine, Seattle Children's Hospital, Seattle, USA
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Monteilh C, Rabon L, Mayer-Hirshfeld I, McGreevy J. Nebulized Tranexamic Acid for Pediatric Post-tonsillectomy Hemorrhage: A Report of Two Cases. Clin Pract Cases Emerg Med 2021; 5:148-151. [PMID: 34436991 PMCID: PMC8143824 DOI: 10.5811/cpcem.2021.2.50799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 02/09/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Tranexamic acid (TXA) use in pediatrics to control hemorrhage has gained interest in recent years, but there is limited literature on nebulized TXA especially regarding dosing and adverse effects. Tranexamic acid has anti-fibrinolytic properties via competitive inhibition of plasminogen activation making it a logical approach to promote hemostasis in cases of post-tonsillectomy hemorrhage. CASE REPORT We describe two cases of post-tonsillectomy hemorrhage managed with nebulized TXA. In both cases, bleeding was stopped after TXA administration. CONCLUSION To our knowledge, this is the first case report to describe the use of nebulized TXA without an adjunct pharmacotherapy. Our two cases add additional reportable data on the safety of nebulized TXA and possible effectiveness on post-tonsillectomy hemorrhage.
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Affiliation(s)
- Cecilia Monteilh
- Phoenix Children's Hospital, Department of Emergency Medicine, Phoenix, Arizona
| | - Lydia Rabon
- Phoenix Children's Hospital, Department of Emergency Medicine, Phoenix, Arizona
| | - Ilana Mayer-Hirshfeld
- Valleywise Health Medical Center, Department of Emergency Medicine, Phoenix, Arizona
| | - Jon McGreevy
- Phoenix Children's Hospital, Department of Emergency Medicine, Phoenix, Arizona
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Monteilh C, Calixte R, Burjonrappa S. Controversies in the management of neonatal testicular torsion: A meta-analysis. J Pediatr Surg 2019; 54:815-819. [PMID: 30098810 DOI: 10.1016/j.jpedsurg.2018.07.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Revised: 05/10/2018] [Accepted: 07/03/2018] [Indexed: 11/27/2022]
Abstract
OBJECTIVE This meta-analysis seeks to discern the optimal management strategy in neonatal testicular torsion (NTT). METHODS Reviewed all English-language articles published between 2005 and 2015 in Medline/Pubmed that had a defined diagnosis of NTT within the first thirty days of life, and discussed specific surgical and nonsurgical management. Exclusion criteria were non-English literature, case reports, case studies, and failure to clearly describe the management of NTT. Data from 9 studies were analyzed, individually and together as pooled data, using a random effect model with a random intercept to estimate the pooled proportions of interest. Results are presented with 95% confidence interval. All analyses were done in SAS 9.4®. RESULTS 9 publications met criteria for this analysis with a total of 196 patients. Bilateral testicular torsions (n = 14) were less common as compared to right/left testicular torsion (n = 85/97). Asynchronous NTTs (n = 9) were more common than synchronous NTTs (n = 2). There was a higher incidence of NTT in neonates delivered by vaginal delivery (n = 110) as compared to those delivered by c-section (n = 25). Extravaginal torsion (n = 54) is far more common than intravaginal torsion (n = 2). Full-term neonates (n = 122) have a higher incidence of NTT as compared to preterm neonates (n = 9). A total of 15 testicles were salvaged. Of the salvaged testicles 2 were documented as prenatal, 10 postnatal and 3 were undocumented. A strategy of bilateral exploration allows for salvage of about 7% of ipsilateral testicles and prevent asynchronous torsion in about 4% of neonates. CONCLUSIONS Based on our population, between 8-12% of patients would benefit from bilateral exploration at the time of diagnosis. We recommend urgent bilateral exploration with orchiopexy of the contralateral testicle in order to avert anorchia. TYPE OF STUDY Systematic review. LEVEL OF EVIDENCE Level 5 meta-synthesis (Evidence from systematic reviews of qualitative and descriptive studies).
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Affiliation(s)
- Cecilia Monteilh
- Department of Pediatrics, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Rose Calixte
- Department of Biostatistics, NYU-Winthrop Hospital, Mineola, New York, USA
| | - Sathyraprasad Burjonrappa
- Department of Pediatric Surgery, NYU-Winthrop Hospital, Mineola, New York, USA; Department of Pediatric Surgery, Montefiore Medical Center, Bronx, New York, USA.
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Abstract
Hoverboards burst onto the scene with wide popularity only to be quickly deemed unsafe and banned in many arenas. We conducted a retrospective cohort study of 35 patients seen in our outpatient pediatric orthopedic office over a 1-year period. The mean age of injured patients was 11.14 years; 18 patients were male (51.4%), and 17 were female (48.5%). The highest number of injuries occurred in children 10 to 14 years old who had 57.1% of the injuries. There were a total of 31 fractures in 27 patients. Most of the fractures were in the upper extremities (93.6 %). Also, 9 soft-tissue injuries were found in 8 patients; 88.9 % of injuries occurred in the upper extremities. Most of the injuries were secondary to a fall (94.3%). We found that the most common injury was upper-extremity fracture. We suggest restricting riding <16 years and encourage protective equipment, especially elbow and wrist guards.
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Affiliation(s)
| | - Prina Patel
- 1 Winthrop University Hospital, Mineola, NY, USA
| | - John Gaffney
- 1 Winthrop University Hospital, Mineola, NY, USA
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Gerr F, Marcus M, Monteilh C, Hannan L, Ortiz D, Kleinbaum D. A randomised controlled trial of postural interventions for prevention of musculoskeletal symptoms among computer users. Occup Environ Med 2005; 62:478-87. [PMID: 15961625 PMCID: PMC1741055 DOI: 10.1136/oem.2004.015792] [Citation(s) in RCA: 75] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To examine the effect of two workstation and postural interventions on the incidence of musculoskeletal symptoms among computer users. METHODS Randomised controlled trial of two distinct workstation and postural interventions (an alternate intervention and a conventional intervention) among 376 persons using computer keyboards for more than 15 hours per week. The incidence of neck/shoulder symptoms and hand/arm symptoms during six months of follow up among individuals in the intervention groups was compared to the incidence in computer users who did not receive an intervention (comparison group). For individuals in the intervention groups, study staff adjusted workstations, where possible, and trained individuals to assume the intervention postures. Individuals reported musculoskeletal symptoms in a weekly diary. Participants who reported discomfort intensity of 6 or greater on a 0-10 visual analogue scale or who reported musculoskeletal symptoms requiring use of analgesic medication were considered symptomatic. RESULTS There were no significant differences in the incidence of musculoskeletal symptoms among the three intervention groups. Twenty two (18.5%) participants in the alternate intervention group, 25 (20.2%) in the conventional intervention group, and 25 (21.7%) in the comparison group developed incident arm or hand symptoms. Thirty eight (33.3%) participants in the alternate intervention group, 36 (31.0%) in the conventional intervention group, and 33 (30.3%) in the comparison group developed incident neck or shoulder symptoms. Compliance with all components of the intervention was attained for only 25-38% of individuals, due mainly to the inflexibility of workstation configurations. CONCLUSIONS This study provides evidence that two specific workplace postural interventions are unlikely to reduce the risk of upper extremity musculoskeletal symptoms among computer users.
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Affiliation(s)
- F Gerr
- Department of Occupational and Environmental Health, College of Public Health, University of Iowa, Iowa City, IA 52242, USA.
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Abstract
UNLABELLED Sjögren's syndrome is uncommon in children, and occurs most often in association with autoimmune diseases (secondary Sjögren's syndrome). We describe the clinical and biological features of a 13-year-old girl with primary Sjögren's syndrome, revealed by recurrent parotitis. CASE REPORT This adolescent girl was referred for investigation of multiple episodes of bilateral parotid swelling since age nine, without systemic symptoms. Examination was unremarkable except for enlarged and painless parotid glands. Laboratory investigations, measurement of saliva production, parotid sialography, labial salivary gland biopsy, revealed Sjögren's syndrome without associated disease. Hydroxychloroquine was prescribed with clinical improvement. CONCLUSION Recurrent parotitis in children is an uncommon condition. The onset of parotid swelling at five years or over deserves screening for dysimmune disorders, sarcoidosis or Sjögren's syndrome. Diagnosis of Sjögren's syndrome is based on laboratory evidence of autoimmune disorders and minor salivary gland biopsy.
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Affiliation(s)
- M C Thouret
- Service de pédiatrie, hôpital de l'Archet, CHU Nice, 151, route de Saint-Antoine-de-Ginestière, 06202 Nice, France
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