Predicting TBI: Prediction rules or judgment?

Andrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t in the room that day, we’re going to be counting them down over here.

Comparison of Prediction Rules and Clinician Suspicion for Identifying Children with Clinically Important Brain Injuries After Blunt Head Trauma

Atabaki SM, et al. Academic Emergency Medicine 2016.

Unmet Needs Addressed

CT imaging has been overused to evaluate children with blunt head trauma despite associated risks to patients and costs. PECARN developed prediction rules to determine which children are at very low risk for clinically important traumatic brain injury (ciTBI). But how do these rules compare to clinical suspicion? In cases when the clinician had a low suspicion for ciTBI but ordered a CT anyway, this study determined reasoning for obtaining the CT.

Methods

  • Secondary analysis of data collected at 24 PECARN centers that derived and validated the original prediction rules.
  • The validation sample was used for analysis to minimize potential bias that would come with using the derivation sample.
  • The clinician suspicion of ciTBI was recorded on a scale. Less than 1%, 1-5%, 6-10%, 11-50%, and greater than 50%. Clinician suspicion did not have the benefit of the prediction rules since these were still being developed.
  • The study also asked for indications for CT when the suspicioin for ciTBI was less than 1%.

Main Results

  • For children under 2 years old, the sensitivity of the prediction rule for predicting ciTBI was 100% while the sensitivity of the clinician was 60%. The specificity of the rule was 54% while the specificity of clinical suspicion was 92%.
  • In children over 2 years old the sensitivity and specificity were similar to the under 2 group.
  • There were 7,688 children in which the clinical suspicion of ciTBI was less than 1%. Over a quarter of these patients (2,099) had a CT and these CTs identified 32 instances of ciTBI. The following is a table of the rationale for obtaining a CT in these children.

Why Did This Make Our Top 10?

  • Clinical decision rules were more sensitive than clinical suspicion
  • Clinical suspicion was more specific than clinical decision rules
  • Clinicians still ordered CTs when their suspicion for ciTBI was less than 1%
  • CT rates are likely higher in settings without PEM providers
  • Translating knowledge can address influences of clinician suspicion

Epinephrine or Dopamine? Results may shock you

Andrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t in the room that day, we’re going to be counting them down over here over the next few weeks.

Double-Blind Prospective Randomized Controlled Trial of Dopamine Versus Epinephrine as First-Line Vasoactive Drugs in Pediatric Septic Shock

Ventura AM1, Shieh HH, Bousso A, et al. Critical Care Medicine. 2015.

Unmet Needs Addressed

Sepsis results in high rates of mortality. That is a problem. While some diagnostic and treatment guidelines for pediatric sepsis exist, some areas remain debatable. One of those debates is what is the best first-line vasoactive infusion for children with fluid-refractory shock?

Methods

  • Single center, prospective, randomized, double-blind trial in a pediatric ICU in São Paulo, Brazil
  • Children 1 month to 15 years old who met clinical criteria for fluid-refractory septic shock were screened for eligibility
  • Exclusion: Children receiving vasoactive drug(s) before hospital admission, known cardiac disease, prior study enrollment during same hospital stay, DNR
  • Data were collected between 2009-2013
The study defined fluid-refractory shock as:

Clinical signs of hypo-perfusion

  • Abnormal heart rate for age
  • Altered/decreased mental status
  • Altered capillary refill time (>2 seconds or flash)
  • Diminished or impalpable or bounding peripheral pulses
  • Mottled cool extremities
  • Urine output <1ml/kg/hr

DESPITE fluid bolus of at least 40 ml/kg

They compared various doses of epinephrine (0.1, 0.2, and 0.3 mcg/kg/min) and dopamine (5, 7.5, and 10 mcg/kg/min) via a PIV or intraosseous line.

Main Results

There were 120 children with fluid-refractory septic shock studied.

Check out the Kaplan-Meyer for epinephrine versus dopamine.

It’s not clear how the editors allowed this chart to use shades of grey for the lines instead of a dotted line. But it suggests that children in the dopamine group died earlier and children in the epinephrine group had an increased odds of survival (6.49). The rate of adverse events were similar.

The dopamine group had a higher percentage for hospital-associated infections compared to the epinephrine group (18/63 patients and 4/57 patients, respectively).

How Did This Make Our Top 10?

Using epinephrine as the first-line vasoactive infusion for children with fluid refractory shock was superior to dopamine. The results admittedly must be replicated.

In addition, peripheral and intraosseous lines were effectively used for early initiation of vasoactives.

Dance teachers were right: Rhythm can save lives

TOPTENAndrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t one of the tens of thousands of people in the room that day, we’re going to be counting them down over here over the next few weeks.

Use of a Metronome in Cardiopulmonary Resuscitation: A Simulation Study

Zimmerman E, Cohen N, Maniaci V, Pena B, Lozano JM, Linares M. Pediatrics. 2016.

Unmet needs addressed

Poor quality CPR contributes to poor outcomes after cardiac arrest. CPR has to be hard and fast. But “how fast and how hard” can be difficult to figure out while standing on that stool trying to save someone’s life. In adult manikins, using a metronome—that ticking device last seen in music class—during CPR can be effective in maintaining target chest compression rate. The question this study tried to address was whether using something as simple as metronome guidance could improve pediatric CPR?

Methods

This was a prospective, cross-over, randomized control trial done in a simulation setting. Medical students, residents, fellows, and nurses working in pediatrics and who had BLS training were randomized to perform two rounds of chest compressions. In one round they used an audible metronome build into the defibrillator that was set at a rate of 100 times per minute. In the other round of chest compressions they did not use a metronome.

The crossover design means that all participants used the metronome, controlling for variability of CPR skill between individuals. Study participants were blinded to the purpose of the study and performed the CPR on a simulation manikin that collected data on the quality of compressions.

Adequate compression rate was defined as being between 90 and 110 compressions per minute and an adequate depth was between 38 to 51 mm.

Main Results

Screen Shot 2017-02-08 at 2.14.38 PMMetronome use in CPR was associated with a higher percentage of compressions with an adequate rate than if the metronome was not used. Without the metronome, about 39% of compressions were too fast while the percentage of compression that were too slow wasn’t significantly different whether the metronome was used or not.

The metronome did not affect depth of compressions.

How did this make our Top Ten?

If adding an audible rhythm improves CPR then metronomes could be integrated into hospital monitors, defibrillators, and AEDs to improve pediatric resuscitation. We could incorporate metronomes into CPR training. Finally, we could finally get “Stayin’ Alive” out of our heads once and for all.

Using an iPad to Remotely Assess Seriously Ill Kids

TOPTENAndrea Cruz (Texas Children’s) and Michelle Macy (Michigan) presented the best PEM-related articles of 2016 at AAP this past October. If you weren’t one of the tens of thousands of people in the room that day, we’re going to be counting them down in no particular order over the next few weeks. 

#10: Reliability of Telemedicine in the Assessment of Seriously Ill Children

Siew L, Hsiao A, McCarthy P, Agrawal A, Lee E, Chen L. Pediatrics. 2016.

Unmet needs addressed

Telemedicine has the potential to bridge the distance between the provider and the patient, expand access to specialized care, and would make it feasible to evaluate ill children remotely. But PEM is different than dermatology and hospital medicine, which both have shown promise in using telemedicine. For PEM to integrate telemedicine into widespread practice, it’s important to know if telemedicine is reliable enough to make clinical recommendations and decisions.

Methods

The study was prospective and done in an urban tertiary care pediatric ED with 35,000 annual visits. The study compared telemedicine observations to bedside observations in assessing two specific PEM populations: febrile children 2-36 months old and children 2 months to 18 years in respiratory distress. Patients were excluded if they were thought to be “clinically too unstable.” Authors used inter-rater reliability to determine if telemedicine observations were significantly different than bedside assessments.

Bedside and telemedicine observers completed their Yale Observation Scales (for febrile patients) or Respiratory Observation Checklists (for respiratory patients) at the same time and were blinded to each other’s assessments.

The telemedicine was done using FaceTime on an Apple iPad with an assistant holding the iPad and controlling the distance and camera angles. The observer could ask for different angles and views.

Main Results

The study found excellent agreement on both febrile children and children in respiratory distress between telemedicine and bedside observations (kappa > 0.8). This suggests that both bedside observation and telemedicine came to similar conclusions when it came to these two populations of sick children.

How did this make our Top Ten?

  • This means that fever and respiratory distress—both common conditions seen in children—may be assessed remotely by clinicians with pediatric expertise.
  • The use of iPads means that the technology is both accessible and (relatively) affordable.
  • There is lower agreement between bedside and telemedicine observation for intercostal retractions. Perhaps this was due to camera and Wi-Fi limitations.
  • Integration of telemedicine into routine PEM practice would require use of platforms that would seamlessly link into the electronic health record in a way that preserves patient confidentiality.

It’s PEM Academic Meeting Season and John Oliver Rails on Bad Science

Whether you’re asking the questions, teaching trainees, or incorporating evidence into your daily practice, many of us in PEM rely on sound research. With many recovering from the nerdy hangover of the recent Pediatric Academic Societies meeting and this week’s Society for Academic Emergency Medicine meeting activities, I have been thinking about how to digest the all of the posters, platform presentations, and calls for further studies on every topic.

John Oliver—Daily Show correspondent turned incredulous HBO news anchor—dedicated a 20-minute segment on how science is interpreted and reported today. And spoiler alert: He was not pleased. He pointed out the varying outlandish scientific report such as how much your dog hates hugs and the importance of flatulence. It’s a humorous yet sobering reminder of the common pitfalls of interpreting science and how the incentives in academic publishing can be distorting.

Watching the segment is entertaining. But if you’ve become too busy for humor and joy, this is what I took away from this.

  • Studies—especially small ones—need validation before they are genaralizeable yet the incentives for performing these studies are small. Researchers get kudos for new discoveries yet are ignored or even mocked (behind closed doors, of course) for validating existing results and “not adding anything new.“
  • People may cherry pick findings they want to hear. I am guilty of this, as I am a big proponent of exercising very little based on just the headline of a New York Times article.
  • If you read the headline, you might do the same.

  • Statistics may be misleading. Practice change should not be based on glancing at the p-values without looking at the methods and actual results. While sometimes painful, journal clubs and critical reading may be a remedy for this when done well.
  • The media may mean well but can simplify and distort conclusions. Some journalists are as guilty as some academics of reading abstracts and press releases before taking a few shortcuts in an effort to get in front of the news cycle.

Many of these flaws in science have always existed although the growth of digital media also amplifies many of them. How will PEM—which many of us consider a young and innovative specialty—handle this delicate academic balance?