PEM Journal Club - Barbara Blackie MD, FRCPC

PEM Acute Care

Smith, Jaron A., et al. "Association of outcomes in point-of-care lung ultrasound for bronchiolitis in the pediatric emergency department." The American Journal of Emergency Medicine 75 (2024): 22-28.

It’s that time again- respiratory season, with the last two winters seeing record numbers of sick children, odd timing and overlap of the usual viral culprits in a still pressured health care system, regardless of country of practice. 

Bronchiolitis, one of the most common presentations this time of year, presents a burden on the babies affected, families and health care systems. There is an abundance of literature on the investigation and management of this condition, and to boil it down, it is a clinical diagnosis, and not much works to treat it except time, and in some cases oxygen supplementation. But what if there was a way to maybe stratify disease and predict who might be fine versus those who will need admission or a higher level of intervention? 

Smith et al published a small study in October of 2023 using point-of-care ultrasound and a scoring system to identify associations between lung ultrasound (LUS) and respiratory support (RS) at 12 and 24 h, maximum RS during hospitalization, disposition, and hospital length of stay (LOS). LUS was performed at the bedside by a physician.

Lungs were divided into 12 segments and scanned, then scored and summated (min. 0, max. 36) in real-time accordingly: 0 - A lines with <3 B lines per lung segment. 1 - ≥3 B lines per lung segment, but not consolidated. 2 - consolidated B lines, but no subpleural consolidation. 3 - subpleural consolidation with any findings scoring 1 or 2.

They then performed a chart review on all 82 enrolled patients after discharge. On analysis of scoring, higher LUS scores for AB were associated with increased respiratory support, longer LOS, and more acute disposition. Mean differences for all dispositions and RS time points were statistically significant (p < 0.05, CI >95%).

The use of bedside LUS in the ED may assist the clinician in the management and disposition of patient's diagnosed with AB.  A small study, but interesting potential for those trying to decide the disposition for babies with bronchiolitis, using POCUS as an adjunct.

PEM Trauma

Freire, Gabrielle C., et al. "Clinical practice guideline recommendations for pediatric multisystem trauma care: a systematic review." Annals of Surgery 278.6 (2023): 858-864.

Friere et al published a systematic review in December of 2023 that is worth a look- Clinical Practice Guideline Recommendations For Pediatric Multisystem Trauma Care A Systematic Review- they analyzed 19 CPG from an initial search yielding over 46000 documents, then create 64 recommendations of various strengths. Of the 19 selected CPGs (11 high quality and 8 low quality), 8 were from the USA, 7 were from the UK, 2 were from Europe, 1 was from Canada, and 1 was international.

Fourteen guidelines (74%) were published in the last 5 years. Ten (53%) CPGs were specific to pediatric populations, and all were targeted toward clinicians.  The recommendations collected from the high quality CPG included the following topics: trauma readiness and transfer (n= 6), resuscitation (n= 24), diagnostic imaging (n=22), pain management (n= 3), ongoing inpatient care (n=6), and family presence and psychosocial support (n=3). Eighteen recommendations (28%) appeared in more than one CPG. 

Highlights of the high-quality recommendations included were related to the application of pressure and tourniquets to stop massive external bleeding, having separate massive hemorrhage protocols for adults and children, the use of PECARN and NEXUS rules to determine the need for cervical spine radiographs in children 3 to 16 years of age, and the use of radiographs to assess thoracic and lumbar injuries in children. 

For practitioners looking for good quality guidelines on managing pediatric major trauma, this is a useful review article, particularly if working in a mixed environment with a low volume of such cases or anticipating building a trauma service. The etable 7 has the complete list of recommendations and where to find, as well a as ranking of evidence quality. 

There are two other systematic reviews mentioned in this article looking at other management aspects of pediatric trauma, including injuries resulting from maltreatment, as noted below.

Complementary reading:

Moore L, Freire G, Ben Abdeljelil A, et al. Clinical practice guideline recommendations for pediatric injury care: protocol for a systematic review. BMJ Open. 2022;12:e060054.

Blangis F, Allali S, Cohen JF, et al. Variations in guidelines for diagnosis of child physical abuse in high-income countries: a systematic review. JAMA Netw Open. 2021;4:e2129068.