Background

Pediatric preparedness in emergency departments (EDs) in Georgia has not been systematically assessed. In most hospitals, pediatric emergencies are attended by a general pediatrician, while more severe cases are referred to adult intensivists, surgeons, or anesthesiologists.

Objectives

The purpose of this study is to measure pediatric emergency preparedness in Georgia using in situ simulations and surveys of general emergency departments, and improve preparedness through gap analysis and action plans.

Methods

This prospective multicenter cohort study involves all EDs in Georgia. Each site will complete a survey to assess pediatric preparedness across six domains (QI, policies, safety, staffing, equipment, coordination). This program also includes an assessment of performance by inter-professional teams caring for four standardized simulated pediatric patients.

Results

To date, we have conducted the pediatric readiness survey in six hospitals in the region of Tbilisi. The in-situ simulations were conducted in three hospitals to date. Preparedness in Georgia seemed to be higher in EDs with higher patient volume. The median readiness score was 37.4/100 points with the weakest areas being quality improvement, care coordination and quality improvement efforts. Regarding the simulation scenarios, sepsis was the most challenging case (median 33%) for all hospitals while the performance during the seizure scenario was the strongest (median 43%).

Conclusion

Our results suggest that pediatric preparedness in Georgia is consistently low across six hospitals visited to date. Further visits in other areas of the country and the simulation-based assessment will help further characterize this finding, and these assessments form the basis for future improvement efforts in the Country.

Background

In today’s simulation manikins anatomical mechanics and aesthetics are ignored, resulting in an incorrect haptic experience for a medical trainee who needs to learn the lifesaving chest compression procedure.

Objectives

Within this paper we detail the process of producing a neonatal ribcage with realistic mechanical , aesthetic, and haptic properties using 3D printing.

Methods

One rib model was printed using the ABS material in multiple thicknesses and print angles. These ribs were tested for mechanical properties using a force gauge (Figure 1). The results were organized and compared to literature.

Figure 1. Picture of force gauge measuring strength rib

Results

In Table 1 & 2 the results of the force gauge tests are depicted.

Conclusion

We conclude that the ABS material, with a 10% increase in thickness, and printed under a 0 to 10 degree angle replicates neonatal bone properties best, and provides a more realistic mechanical, aesthetic, and haptic representation to use in simulation manikins.

Background

Newborn life support (NLS) manikins have been used for clinical training for over 30 years. Over this period the mechanical construction of manikins has changed little, as reflected in their continued poor anatomical and physiological fidelity. This poor fidelity may inadequately prepare clinicians to deliver sufficiently deep and consistent chest compressions (CCs) during cardiopulmonary resuscitation.

Objectives

We aim to develop a NLS manikin with higher human fidelity by employing a combination of MRI imaging, 3D printing, material selection, and casting.

Methods

Using a full body MRI scan of a 37-week old newborn, a replica of the bone structure and molds of the thoracic organs was 3D printed. After casting in Ecoflex 5 silicone, the prototype NLS manikin was assembled (Figure 1 (top)). To validate its fidelity force-displacement tests were performed on a Resusci Anne manikin and the prototype NLS manikin design following NLS CC guidelines (Figure 1 (bottom)). These data were then quantitatively compared to compression data from rabbits [1].

Results

Figure 2 shows that the prototype NLS manikin exhibits more non-linear force-displacement behavior than the Resusci Anne manikin which showed a linear behavior.

Conclusion

The results suggest that the prototype has higher human fidelity.

References

[1] Lloyd, D., Development and validation of a feedback device suitable for resuscitation of premature infants. Master’s Thesis, Stellenbosch University, (2016).

Background

Volume replacement in the case of neonatal shock represents a rapid and difficult decision. The hematocrit and blood pressure often could not help in this decision.

Objectives

To present situations in which the regional cerebral oxygen saturation(cRSO2) and fractional tissular oxygen extraction(FTOE) could aid in the decision for blood transfusion in neonates with different forms of shock

Methods

There are presented several cases of neonatal circulatory failure in which blood transfusion was indicated. There are noted the values of hematocrit, blood pressure, capillary refill time and cRSO₂ and cerebral FTOE. There are presented two cases of pulmonary hemorrhage, one cord blood hemorrhage, one case of digestive hemorrhage and one case of perinatal asphyxia because of placental abruption.

Results

All cases had signs of shock :pallor, cold extremities, increased capillarry refill time and tachypnea, blood pressure was normal and did not predict the need for transfusion. The hematocrit was decreased immediately after pulmonary hemorrhage but not after the cord blood hemorrhage. The cRSO2 was the strongest predictor of need of transfusion in all the cases, decreasing in about 20 minutes with more than 20% from the baseline, the periferal SO2 being normal all the time. The cRSO2 came back to normal values after the transfusions in all the cases.

Conclusion

The cRSO2 are a sensitive predictor in the case of acute anemia in this series of cases and could help in the decision of a timely and efficient transfusion in the neonates with shock.

Background

APLS states that calcium should be administered during a paediatric cardiac arrest only when specifically indicated, for example, in cases of calcium channel blocker overdose, a rare occurrence in paediatrics. High dose insulin therapy in these cases is well documented in adult medicine, but is rarely used in paediatrics.

Objectives

We present the case of a 4 year old boy with Cockayne syndrome and hypertension, who developed nifedipine toxicity secondary to an acute kidney injury and 2.5mg/kg of nifedipine as a single dose. Cardiac arrest followed, requiring IV calcium gluconate (3 doses of 0.11mmol/kg) for return of spontaneous circulation (ROSC). There was ongoing, inotrope resistant, bradycardia following ROSC which was successfully was treated with high dose insulin therapy (1 unit/kg bolus then 1 unit/kg/hr infusion).

Methods

We additionally performed a systematic literature review of articles published prior to January 2019 using PubMed and Google Scholar (search terms: paediatric, calcium channel blocker, insulin). We identified articles which addressed the use of high dose insulin therapy in paediatric (under 16 years) calcium channel blocker toxicity.

Results

Few case reports of paediatric patients exist, those which do range in age between 5 months and 14 years.

Conclusion

There is growing evidence for the use of high dose insulin therapy in the management of calcium channel blocker toxicity in adult patients, with limited evidence in paediatrics. Additional clinical research and prospective clinical studies are needed to confirm the safety and efficacy of high dose insulin therapy in the paediatric population.

Background

‘Near-hanging’ describes survival following a hanging incident; eventual outcome includes death or neuro-disability.

Objectives

Examine mechanism, organ dysfunction, management, and associations with outcome, for admissions to our PICU following near-hanging.

Methods

Retrospectively identify all PICU admissions 2008-2018, gather routinely collected clinical data. Two tailed Fischer’s exact test and unpaired T-test performed.

Conclusion

Results:

·15 patients (11 months – 16 years, 11/15 male)
·8 suicide attempts, 7 accidental.
·7 children had good outcome (GCS 15 on discharge from PICU).
·8 children had poor outcome – 6 died, 2 neurological impairment.
·Poor outcome was significantly associated with cardiac arrest, pulmonary oedema, and abnormal LFTs.
·Three children with good outcome had a worst recorded GCS of 3.

Conclusions:
Near-hanging is a rare cause of PICU admission. Multiple organ dysfunction is common, as is death and disability. Cardiac arrest had universally poor outcome, as per previous studies.
Pulmonary oedema and abnormal LFTs were also significantly associated with poor outcome, a new finding, though sample size is small.
This supports previous work, and suggests multiple organ failure heralds a poor prognosis.

Acknowledgements:
Thanks to Dr Stuart Hartshorn and Dr Kevin Morris for their support.

References: van Hasselt TJ, Hartshorn S. Hanging and near hanging in children: injury patterns and a clinical approach to early management. Archives of Disease in Childhood - Education and Practice Published Online First:09 July 2018. doi: 10.1136/archdischild-2018-314773

Background

Trauma in Portugal continues to be one of the main causes of death in children and adolescents. Yet, there is a shortage of population-based studies about weapon related trauma in our country.

Objectives

To describe patients hospitalized for weapon related trauma in a Portuguese Pediatric Intensive Care Unit.

Methods

Retrospective study through clinical processes analysis of hospitalized cases for a period of 10 years (January 2006 to December 2017).

Results

Were included 9 cases, 88,9% were male and mean age was 11,3 years. A firearm was used in 66.6% and a white weapon in the remaining cases, 44.4% happened at home, mainly on weekend. Two cases were suicide attempts while in the others the aggressor was either a friend, family or a neighbor. In 5 cases the aggression was intentional, 55,6% the injury was in the head, whereas the rest was in abdomen, back or neck. During hospitalization, all patients were intubated, 5 underwent surgery and 4 required inotropic and transfusional support. Median length of stay was 14,5 days. Overall mortality was 22,2%, corresponding to a 5 and a 14-year-old male, both with severe traumatic brain injury. Of those two patients, Pediatric Risk of Mortality calculated through PRIM III score was 29 and 30 and probability of death was 0.597 and 0.673, respectively. One patient persisted with major sequels and one with minor.

Conclusion

Weapon injuries in children can be associated with severe adverse outcomes including death, which makes this a significant public health problem and a focus to prevention measures in risk groups.

Background

Poppy seed is used frequently in Turkey and globally and has an economic value since it is used as an industrial plant.

Objectives

Papaver somniferum subsp. anatolicum var. nigrum(blind poppy) is the variant that is mostly used in agriculture and consists of over 35 kinds of alkaloids including morphine, codeine, tebaine, noscapine and papaverin.

Methods

Here-in we report fatal course of 4 year-old girl due to excessive raw poppy plant ingestion.

Results

Previously-healthy, 4-year-old girl was brought to the emergency department with a complaint of loss of consciousness. Her family was occupied as poppy seed farm workers and they reported that they ate raw poppy plants approximately 12 hours prior. Physical examination revealed as tachycardia, hypertension, no response to painful stimuli and hyperactive deep tendon reflexes. Intravenous naloxone was administered after plasma opioid level was reported to be 1196 ng/mL and she had a brief gain of consciousness. Laboratory analysis showed elevated serum lactate and creatinine kinase levels. Large amounts of poppy seed were extracted during gastric lavage, however, after 7 days of admission, poppy seed has been seen in lavage. Due to all mechanical support, renal replacement therapy or other standard care, she died at the 12^thday of her PICU admission. Analysis of the poppy showed unusually high levels of morphine, codeine, acetylhydrocodeine, papaverin and atropine alkaloids.

Conclusion

Raw poppy seed ingestion could be fatal during childhood, and clinical and laboratory findings might be related with the alkaloid ingredients.

Background

Thyroglossal duct cyst (TGDC)are rare but most common cause for congenital neck masses. Antenatal diagnosis of TGDC is possible and airway obstruction at birth or in early infancy can be anticipated.

Objectives

Case Report TGDC

Methods

A 20 day old term male neonate presented with stridor since birth and progressively increased over days. Antenatal ultrasonography in 3rd trimester had shown a cyst at the base of the tongue measuring 1.1x1.0x1.0 cm (volume 0.67cc). The findings were confirmed with CT scan after birth(Figure 1). Thyroid position and functions were normal. Direct laryngoscopy was done under general anesthesia before surgery(Figure 2). 1.5 ml of mucoid fluid was aspirated to decompress the cyst. Marsupialization and bipolar coagulation of cyst wall done and 0.5 ml Bleomycin was injected at base. Post-operatively baby was electively ventilated for two days. Histopathological examination of cyst wall was suggestive of TGDC (Figure 3). Follow-up scans showed complete resolution with no recurrence.

Figure 1: CT scan Saggital and Coronal View showing cyst within base of tongue.

Figure 2: Direct Laryngoscopy view before surgery showing cyst*

Figure 3: Histopathological image of cyst showing pseudostratified columnar epithelium

Results

Lingual TGDC is a rare cause of stridor in neonates often misdiagnosed as laryngomalacia. Endoscopic marsupialization is the treatment of choice. Recurrence is rare.

Conclusion

The diagnosis of TGDC should be kept in mind in a neonate with stridor or acute airway obstruction.Surgical excision by intra-oral approach is suitable for management of pure lingual TGDC with Sistrunk’s procedure being reserved for those that extend into the neck.

Background

Standardized patient transportation and transfer is a dynamic, quick-acting process, nevertheless crucial for clinical decision-making, and safe for high-quality and continuous care. Mobilizing and structuring this phase contributes to successful communication among medical professionals by improving transmission of an accurate information that is significantly important for patient safety and continuous health care.

Objectives

To create and implement a high-quality working instrument to improve and standardize patient transfer process from cardio-surgical operating room to intensive care unit in Childrens Clinical University Hospital in Latvia, as well as evaluate performance and effectiveness of developed handover protocol.

Methods

Qualitative study method, development and analysis of standardized handover protocol.

Results

Standardized handover protocol for more efficient patient transporting from cardio-surgical operating theater to pediatric intensive care unit was developed and integrated in patient transportation process. The introduction of handover protocol provides a single document that includes both short-term and long-term care, treatment goals for cardiovascular patients. A survey among medical professionals has been conducted to assess protocol effectiveness and validate its implementation.

Conclusion

The introduction of the protocol is a new and unusual practice in PICU Latvia. In order to implement this and improve the transfer process in children's hospital, significant changes are needed in the culture and organisation of all doctors, nurses, including the establishment and adaptation of the protocol itself. Completion of the normal transformation and standardisation of the transfer process, understanding and education of the new process.

Background

High and Low Fidelity Simulation Scenarios are used for health professionals in order to improve their crisis resource management (CRM) and medical skills. Our Neonatal and Paediatric Transport Team (NPTT) has been using this kind of simulation since 2014.

Objectives

To Describe the benefits of a simulation program for a NPTT from participants' point of view.

Methods

Six transport team members are high-fidelity simulation instructors. The needs of the team were assessed following an internal survey. A complete transport team (a paediatrician, a nurse and a technician) were the participants on each scenario. The scenarios were set in a high fidelity simulation room in our hospital and in our ambulance.

Results

Table 1 summarises the scenarios.

Conclusion

The peculiarities of NPTT demand to their workers to be ready for unexpected and uncommon but threaten events. Then, simulation seems to be the ideal tool to be prepared for it.

Background

Aimed at multi-professional teams from paediatric and neonatal intensive care, transport, palliative care and the hospice setting, a simulation based course has been developed to improve the planning, communication and practical aspects of transferring a ventilated patient for an out-of-hospital, hospice based extubation.

Objectives

To improve the care provided to children and families for whom the direction of care has changed. Particular focus is given to multi-disciplinary team working in advance of complex decision making, supporting simulated actor parents through this process and enabling a smooth, safe transfer through effective planning and co-ordination.

Methods

Established in 2016 and drawing on a multi-professional faculty, this simulation based course encompasses the following:

1) Complex end of life decision making

2) Multi-site liaison to facilitate a transfer

3) Shared learning about the process of transferring a ventilated child from intensive care

4) Actors are used to enable depth and a sense of reality for candidates

Results

This highly evaluated programme addresses the recognised gap in knowledge and the provision of care in this specialised and complex group. Evaluation data indicates improved understanding of the planning and implementation of this type of transfer. Crucially, the multi-agency nature of the course has increased understanding between teams from different sites and allowed them to effectively collaborate in enabling this type of transfer.

Conclusion

The development and delivery of this course demonstrates the effective use of clinical simulation in an interprofessional context. We believe this goes some way towards closing the gap in knowledge and skills in this difficult and sensitive area.

Background

Air medical transport is frequently used in the pediatric population, depending on weather and availability.

Objectives

Utilization and overutilization of transport resources are investigated in this study.

Methods

In this study, over a 5 year period, pediatric scene calls were compared between helicopter transports and ground transports. Severity of injuries, interventions and time in the hospital as well as time on scene and duration of transport were compared. The aim of the study was to evaluate differences between helicopter and ground transport, also in terms of overutilization of resources.

Results

Mean patent age was 8,2±5,4 years. Overall, the age distribution of all patients had two peaks, one in early childhood (diagnosis of seizures) and one in adolecents (diagnosis of trauma). Mean time in the hospital was 2,8±6,3 days for helicopter transport, and 1,6±3,7 days for ground transport (p=0,001)

NACA (National Advisory Committee for Aeronautics)-Scores were significantly higher in helicopter compared to ground transport (3,1±0,9 vs 2,9±0,8, p<0.05). Overutilization (emergency physician was on scene despite not indicated according to NACA Scores) was present in 19.6 % of ground transports, and 19.2 % of helicopter transports. Discharge on day of admission occurred in 28,2 % of cases in helicopter vs. 35,5 % in ground transports.

Conclusion

As shown in this study, overutilization of dispatching emergency physicians to the scene in addition to the EMT team, as well as overutilization of helicopter transport was present in pediatric patients. Careful triaging, communication, and feedback via the emergency command center is necessary to avoid overutilization of scarce and expensive resources.

Background

It is not yet consensual whether parents should accompany their child during interfacility transport and during primary transport to the hospital. However new guidelines have been recently published for neonatal transport encouraging this policy.

Our emergency transport team has accepted to ride with parents in our ambulances for more than ten years, with various results.

Objectives

The aim of this study was to assess the perception of this policy by the members of our team.

Methods

An anonymous survey was sent via an internet link to all driving, nursing and medical staff. Through 4 closed questions, they were asked to assess their perception of parental presence during retrieval. They could also underline the potential advantages and challenges of such policy.

Results

Thirty members (out of 31) of the team answered the survey. Parental presence during retrieval was perceived as “an opportunity” to ease the retrieval for 50% of the staff, compared to 3% considering parental presence as a “burden”. Twenty five percent thought that parental presence had “no influence”.

The most dreadful event (among 7 proposals) which may occur during the ride was an inappropriate parental behavior. The staff's expectation was that parents reassure their child during transfer.

Conclusion

As both medical, nursing and driving staff are ready to allow parental presence during retrieval, it should be included in the routine policy. A further study is needed to check if it doesn’t increase risks during retrieval.

Background

Parental presence during critical care was a major concern a few years ago. The problem is now solved, but there is little evidence about it during interfacility transport and primary intervention.

Objectives

We decided to conduct a study to assess and understand our current policy.

Methods

The prospective monocentric study was conducted from April 2018 to October 2018. Nursing staff was asked to state and rate the parents’ presence during retrieval by means of a standardized questionnaire. We used one answer only questions from a larger survey: “Have you transported one of the parents?” They had to choose one answer out of four: Yes, on their request, Yes on our demand, No they declined, No it wasn’t an option.

Results

Staff questionnaire was returned for 333/709 of the retrievals (47% response rate)

There was a major difference between neonates and older children accompaniment.

Forty percent of the newborns’ parents and 12% of the older children’s parents were not even asked to come with the ambulance. Respectively 17% and 77% of the parents accompanied the ride but 80% and 20% of those who were asked to accompany declined the proposal.

Conclusion

The difference of parental presence during neotate’s or older children’s retrieval is a concern even if the mother’s absence could be partially explained by the fact they needed medical attention after birth. It could be interesting to perform the same type of study in different countries in order to have the advice of caregivers.