Sriram Ramgopal

Background: It is unclear whether time to antibiotics changes outcomes for hospitalized children with community‐acquired pneumonia (CAP) and whether observation is safe. Objective: Our objective was to compare outcomes among children with CAP admitted to the hospital who did and who did not receive antibiotics within 4 h of presentation to the Emergency Department. Methods: We conducted a multicenter, retrospective cohort study using data from four hospitals obtained from the Pediatric Health Information System. Children aged 3 months to 18 years, with a chest X‐ray, admitted to the hospital from the ED with suspected CAP who received antibiotics were enrolled. Our primary outcome was a composite of escalation of care (escalation in respiratory support, transfer to the intensive care unit, vasopressor use, or chest tube placement). Secondary outcomes were length of stay, duration of oxygen use, and cost of stay. Inverse propensity weighted logistic regression and log gamma regression to evaluate the association of early versus late antibiotics and outcome. Results: There were 758 children hospitalized with CAP who met inclusion criteria, of which 451 (59%) received antibiotics within 4 h. There was no statistical difference in escalation of care between those who received early versus late antibiotics (3% vs. 2%; odds ratio [OR]: 1.46 [95% confidence interval [CI]: 0.57,3.73]). There were no statistical associations with secondary outcomes. Conclusion: This study provides an opportunity for antibiotic stewardship by showing that more time to observe patients with CAP without antibiotics does not change outcomes. This time may identify patients who will improve without antibiotics, limiting side effects.

Was not provided for this article.

Objectives To externally validate previously reported centile curves for the mean arterial pressure (MAP) on paediatric acute care samples; derive centile curves for paediatric MAP in an acute care population and evaluate the association of age-adjusted MAP with prehospital and in-hospital outcomes. Design Retrospective observational study. Setting (1) Critical care transport service, (2) multiagency emergency medical services (EMS)and (3) multicentre paediatric emergency department datasets. Patients Paediatric (Intervention(s) None. Main outcome measure Centile for mean arterial pressure. Results We included 4784 critical care transports, 4 221 048 ED encounters and 529 475 EMS encounters. Among critical care transports, the intraclass correlation between calculated and oscillometric MAP was 0.996 (95% CI 0.969 to 0.999). Using previously published MAP criteria in the ED sample, 0.1% of encounters fell below the 5th centile, whereas 32.2% were above the 90th centile and 17.7% above the 95th centile; in the EMS sample, 0.6% were below the 5th centile, whereas 55.7% were above the 90th centile and 41.0% above the 95th centile. MAP centiles aligned well with internal validation but were less accurate in the EMS sample, where 16.9% of neonates had a MAP below the 5th centile. Lower MAP was associated with increased mortality, vasoactive use and intravenous fluid use. Conclusion We describe age-specific reference distributions for paediatric MAP across a large contemporary clinical population. These findings offer a framework for interpreting an individual child’s MAP and may assist in establishing clinical norms and prediction modelling applications.

INTRODUCTIONChildren represent a small and challenging population for emergency medical services (EMS) clinicians. Only 5-10% of patients treated by EMS are children and most of these encounters ar...

Aortic emergencies (AE) – aortic dissections (AD) and ruptured aortic aneurysms (AA) – are rare but potentially life-threatening diseases commonly encountered in emergency departments and during cr...

Objective: To evaluate agreement among three approaches to mean arterial pressure (MAP) measurement in children. Methods: We performed a single-center prospective study of a convenience sample of children (<18 y) presenting to a pediatric emergency department. We compared MAP agreement using the intraclass correlation coefficient (ICC) measured in three ways: calculated via auscultation, calculated from oscillometric systolic and diastolic measurements, and measurement via oscillometry. Results: We included 347 patients (median age 8 y, IQR: 4 to 13). The highest ICC was observed between calculated and device-reported oscillometric MAP measurements (0.83, 95% CI: 0.79-0.86), indicating good agreement. Agreement was poor between manual and device-reported oscillometric MAP (ICC: 0.33, 95% CI: 0.22-0.43) and between manual and calculated oscillometric MAP (ICC: 0.38, 95% CI: 0.20-0.52). The median difference between calculated oscillometric and device-reported oscillometric MAP was 1.0 mm Hg (IQR: 0.0 to 2.3), compared with −3.3 mm Hg (IQR: −8.3 to 2.0) between manual and device-reported oscillometric MAP and −4.0 mm Hg (IQR: −9.3 to 0.3) between manual and calculated oscillometric MAP. Bland-Altman plots suggested that manual MAP measurements were slightly lower than both device-reported oscillometric and calculated oscillometric MAP measurements. Agreement between calculated oscillometric and device-reported oscillometric MAP was highest among children <2 years and lowest among children 12 to <18 years. Agreement involving manual MAP remained poor across most age groups. Similar patterns were observed when stratified by weight and patient state. Conclusions: Calculated oscillometric MAP had good agreement with device-reported oscillometric MAP, while manual MAP had poorer agreement with either oscillometric measure. Further study is needed to determine the clinical implications of these differences across age, weight, and patient-state subgroups.

Emergency medical services (EMS) in the United States (U.S.) are decentralized, resulting in more than 20,000 agencies with variable funding and governance (1), patient care protocols (2–8), and pa...

Objectives: While advanced airway management (AAM) is commonly performed for children with out-of-hospital cardiac arrest (OHCA), the benefit and optimal timing of AAM remains unclear. To determine whether earlier prehospital AAM is associated with patient outcomes compared with later or no AAM in children with OHCA. Methods: Retrospective cohort study of pediatric patients (aged <18 years) with nontraumatic OHCA treated by emergency medical services (EMS), using the Resuscitation Outcomes Consortium Epidemiologic Registry–Cardiac Arrest at 10 sites in the United States and Canada from April 2011 to June 2015. The exposures are early prehospital AAM (defined as successful AAM within 10 minutes of EMS arrival) and any successful prehospital AAM (endotracheal intubation or supraglottic airway placement). The primary outcome was survival to hospital discharge. Children who received successful prehospital AAM at each minute after EMS arrival were matched, using time-dependent propensity scores, to children at risk of AAM in the same minute. Results: Among 954 eligible pediatric patients (median [IQR] age, 1 [0 to 11] years), 521 (54.6%) received prehospital AAM, and 433 (45.4%) did not. Overall, 91 (9.5%) survived to discharge. In the propensity score-matched cohort (922 matched cases), successful AAM ≤10 minutes was associated with higher likelihood of survival to hospital discharge (risk ratio [RR], 1.93; 95% CI, 1.01-3.70) compared with children at risk of receiving AAM. In contrast, when successful prehospital AAM was considered regardless of timing, any successful AAM was not associated with survival (RR, 1.35; 95% CI, 0.75-2.43). Conclusions: In this North American cohort of pediatric OHCA, earlier AAM (successful AAM within 10 minutes) was associated with survival to hospital discharge. However, successful prehospital AAM at any time was not associated with survival to hospital discharge. These findings suggest that performing AAM earlier in the resuscitation may have a potential benefit for children with OHCA.