Search

Anaphylaxis is an acute systemic and potentially fatal allergic reaction. In this study, we evaluated trends in yearly rates of anaphylaxis in a pediatric Emergency Department (ED) in Montreal, Canada.A prospective and retrospective recruitment process was used to find families of children who had presented with anaphylaxis at the Montreal Children's Hospital between April 2011 and April 2021. Using a uniform recruitment form, data were collected. Anaphylaxis patterns were compared to clinical triggers using descriptive analysis.Among 830,382 ED visits during the study period, 2726 (26% recruited prospectively) presented with anaphylaxis. The median age was 6 years (IQR: 0.2, 12.00), and 58.7% were males. The relative frequency of anaphylaxis cases doubled between 2011-2015, from 0.22% (95% CI, 0.19, 0.26) to 0.42 March 2020, the total absolute number of anaphylaxis cases and relative frequency declined by 24 cases per month (p0.05) and by 0.5% of ED visits (p0.05).The rate of anaphylaxis has changed over the years, representing modifications in food introduction strategies or lifestyle changes. The observed decrease in the frequency of anaphylaxis presenting to the ED during the COVID pandemic may reflect decreased accidental exposures with reduced social gatherings, the school closed, and reluctance to present to ED.

Prompt epinephrine autoinjector (EAI) use is the primary treatment for anaphylaxis. However, limited Canadian data exist on the impact of reaction location on EAI use for food-induced anaphylaxis (FIA).We sought to investigate the setting, management, and severity of pediatric FIA.We recruited children presenting with FIA from 11 Canadian emergency departments. Patient demographics and the setting, management, and symptoms of FIA were collected by standardized questionnaire. Factors associated with prehospital EAI use and reaction severity were determined by logistic regression.We recruited 3,604 children; 60.2% were male and the median age was 5.0 years (interquartile range 1.8-11.0). Among cases with a known location of FIA (85.0%), home was the most common setting (68.1%), followed by school/daycare (12.8%), other locations (11.4%; eg, park, car), and restaurants (7.4%). In the prehospital setting, EAI was administered in 36.7% of reactions at home, 66.7% in school/daycare, 40.2% in other locations, and 44.5% in restaurants. Relative to reactions occurring at school/daycare, prehospital EAI use was less likely at home (adjusted odds ratio [aOR] 0.80; 95% CI 0.76-0.84), in restaurants (aOR 0.81; 95% CI 0.75-0.87), and in other settings (aOR 0.77; 95% CI 0.73-0.83), when data were adjusted for reaction severity, sex, age, comorbidities, and province. The FIA setting was not associated with reaction severity or hospitalization.Prehospital EAI use was higher at school/daycare than in other settings, potentially owing to the presence of policies and training on FIA. Setting-specific interventions including educational programs and policies/laws mandating training and stocking an EAI may improve anaphylaxis recognition and treatment.

Data are sparse regarding tree nut-induced anaphylaxis (TNA).To characterize rate, clinical characteristics, and management of TNA in children (0-17 years old) across Canada and evaluate factors associated with severe reactions and epinephrine use.Between April 2011 and May 2020, data were collected on children presenting to 5 emergency departments in Canada. Multivariate logistic analysis was used to evaluate factors associated with severe reactions (stridor, cyanosis, circulatory collapse, or hypoxia) and epinephrine use.Among 3096 cases of anaphylaxis, 540 (17%) were induced by tree nut. The median age was 5.2 (interquartile range, 2.5-9.5) years and 65.4% were of male sex. Among all reactions, 7.0% were severe. The major tree nuts accounting for anaphylaxis were cashew (32.8%), hazelnut (20.0%), and walnut (11.5%). Cashew-induced anaphylaxis was more common in British Columbia (14.0% difference [95% confidence interval (CI), 1.6-27.6]) vs Ontario and Quebec, whereas pistachio-induced anaphylaxis was more common in Ontario and Quebec (6.3% difference [95% CI, 0.5-12.2]). Prehospital and emergency department intramuscular epinephrine administration was documented in only 35.2% and 52.4% of cases, respectively. Severe reactions were more likely among of male sex (adjusted odds ratio [aOR], 1.05 [95% CI, 1.01-1.10]), older children (aOR, 1.00 [95% CI, 1.00-1.01]), and in reactions triggered by macadamia (aOR, 1.27 [95% CI, 1.03-1.57]).Different TNA patterns in Canada may be because of differences in lifestyle (higher prevalence of Asian ethnicity in British Columbia vs Arabic ethnicity in Ontario and Quebec). Intramuscular epinephrine underutilization urges for epinephrine autoinjector stocking in schools and restaurants, patient education, and consistent policies across Canada.

Sesame can cause severe allergic reactions and is a priority allergen in Canada.To assess clinical characteristics and management of pediatric sesame-induced anaphylaxis and identify factors associated with epinephrine treatment.Between 2011 and 2021, children with sesame-induced anaphylaxis presenting to 7 emergency departments (ED) in 4 Canadian provinces and 1 regional emergency medical service were enrolled in the Cross-Canada Anaphylaxis Registry. Standardized recruitment forms provided data on symptoms, severity, triggers, and management. Multivariate logistic regression evaluated associations with epinephrine treatment pre-ED and multiple epinephrine dosages.Of all food-induced anaphylactic reactions (n = 3279 children), sesame accounted for 4.0% (n = 130 children), of which 61.5% were boys, and the average (SD) age was 5.0 (4.9) years. Hummus containing sesame paste triggered 58.8% of reactions. In the pre-ED setting, 32.3% received epinephrine, and it was more likely to be used in boys (adjusted odds ratio [aOR], 1.27; 95% confidence interval [CI], 1.08-1.50) and those with a known food allergy (aOR, 1.36; 95% CI, 1.11-1.68]). In the ED, 47.7% of cases received epinephrine, with older children more likely to receive multiple epinephrine doses (aOR, 1.00; 95% CI, 1.00-1.02).In Canada, hummus is the major trigger of sesame-induced anaphylaxis. Knowledge translation focused on prompt epinephrine use and product-labeling policies are required to limit sesame reactions in communities.

OBJECTIVES Forearm fractures are among the most common pediatric injuries. Procedural sedation is frequently used for analgesia during fracture reduction but requires a prolonged recovery period and can be associated with adverse events. Bier block is a safe alternative for fracture reduction analgesia. This study sought to compare Bier block and procedural sedation for forearm fracture reduction. METHODS We performed a retrospective study of patients aged 6 to 18 years, presenting with forearm fractures requiring closed reduction from June 2012 to March 2014. Outcomes assessed were emergency department length of stay, reduction success rates, adverse events, and unscheduled return visits. RESULTS Overall, 274 patients were included (Bier block, n = 109; procedural sedation, n = 165). Mean length of stay was 82 minutes shorter for Bier block patients (279 vs 361 minutes, P < 0.001). Subanalysis revealed a reduced length of stay among Bier block patients with forearm fractures involving a single bone (286 vs 388 minutes, P < 0.001) and both bones (259 vs 321 minutes, P < 0.05). Reduction success did not differ between Bier block and procedural sedation (98.2% vs 97.6%, P = 0.74). There were no major adverse events in either group, but Bier block patients experienced fewer minor adverse events (2.7% vs 14.5%, P < 0.001). Return visit rates were similar between Bier block and procedural sedation (17.6% vs 16.9%, P = 0.92). CONCLUSIONS Compared with procedural sedation, forearm fracture reduction performed with Bier block was associated with a reduced emergency department length of stay and fewer adverse events, with no differences in reduction success or return visits.

Background Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis. Objective To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use. Methods Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting. Results We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting. Conclusions Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.

Food-induced allergic reactions are diagnosed through corroboration of a suggestive clinical history with appropriate confirmatory tests. The major confirmatory tests include skin prick tests and serum specific immunoglobulin E (sIgE) levels. When the diagnosis is inconclusive, oral food challenges are performed (1).

BACKGROUND Distal forearm fractures are among the most common injuries presenting to the pediatric emergency department (PED). Bier block (BB), or intravenous regional anesthesia, is a safe and effective alternative to procedural sedation for closed reduction of forearm fractures; it is associated with fewer adverse events, a shorter length of stay, and reduced costs. BB has long remained relatively underutilized; however, with an increasing emphasis on efficient resource use and patient-centered care, there is renewed interest in this technique. OBJECTIVE Our tertiary PED recently became the first in Canada to successfully implement an active BB program. Subsequently, we developed a mobile BB smartphone app designed to support the sustained departmental use of BB. The app can be used for training and maintenance of competency and incorporates instructional material, as well as our institutional BB protocol, printable medication order sheets, and monitoring forms. The present report describes the development and functionality of the BB smartphone app. METHODS We have described app development and content. App dissemination metrics will be tracked, and user feedback will be analyzed using a self-administered electronic survey. Additionally, app utilization in our PED will be compared with real-world clinical use of BB for fracture reductions. RESULTS The first iteration of the BB app was launched in 2015, with the most recent update in September 2018. App metric tracking is planned for January 2020 until December 2021. CONCLUSIONS We have highlighted how the BB app serves as a paradigm of an educational tool designed not only for individual users but also for supporting the department-wide implementation and dissemination of a new technique. App dissemination and use metrics will be tracked and correlated with clinical use of BB in the PED. INTERNATIONAL REGISTERED REPOR PRR1-10.2196/10363

Objectives Bier block (BB) is a safe and effective alternative to procedural sedation for analgesia during forearm fracture reductions, yet remains infrequently used in the pediatric emergency department (PED). No standardized methods of BB training have previously been described. The objective of this study was to determine whether a multimodal instructional course increases comfort with BB and translates to increased use of this technique. Methods A novel interdisciplinary simulation and Web-based training course was developed to teach the use of BB for forearm fracture reduction at a tertiary PED. Participants were surveyed pre-/post-training, and at 2 and 6 months regarding their comfort with BB. In parallel, we prospectively assessed the clinical use of BB for children ages 6 to 18 years requiring closed reduction of forearm fractures during the 24-month post-course period. Results Course participation included 26 physicians and 12 nurses. Survey response rate was 100%. Course participation increased both comfort (10% pre-training v. 89% post-training, ppp Conclusions A novel combined simulation and Web-based training course increased comfort and willingness to use BB and was associated with increased use of this technique for forearm fracture reduction in the PED.

Introduction: Distal forearm fractures are one of the most common injuries presenting to the pediatric emergency department. Procedural sedation (PS) is commonly used to provide analgesia during fracture reduction, but requires a prolonged recovery period and can be associated with adverse respiratory events. Bier block (BB) regional anesthesia is a safe alternative to PS for fracture reduction analgesia. We sought to assess the impact of BB on length of stay (LOS) and adverse events following forearm fracture reduction compared to PS. Methods: We performed a retrospective study of patients aged 6 to 18 years, presenting with forearm fractures requiring closed reduction from June 2012 to March 2014. The primary outcome measure was emergency department LOS; secondary outcomes included reduction success rates, adverse events and unscheduled return visits. Results: Two-hundred and seventy-four patients were included for analysis; 109 treated with BB, 165 underwent PS. Overall, mean LOS was 82 min shorter for patients treated in the BB group (279 min vs. 361 min, pConclusion: Compared to PS, forearm fracture reduction performed with BB was associated with a reduced emergency department LOS and fewer adverse events, with no difference in reduction success or return visits.

Introduction: Bier block (BB) regional intravenous anesthesia is a safe and effective alternative to procedural sedation for analgesia during forearm fracture reductions, yet BB remains infrequently utilized in the Pediatric Emergency Department (PED). No standardized methods of BB training have previously been described. The objectives of this study were to evaluate comfort and level of experience with BB in the PED, and to determine if a multimodal instructional course increases these from baseline and translates to increased utilization of this technique. Methods: A novel interdisciplinary simulation and web-based training course was developed to teach the use of BB for forearm fracture reduction at a tertiary PED. Participants were surveyed pre/post training, and at 2- and 6-months regarding their comfort with and willingness to use BB. In parallel, we prospectively assessed the clinical utilization of BB in the PED during the 24-month period immediately following course completion. Results: Course participation included 38 members of the PED (N = 26 physicians, 12 nurses), and survey response rate was 100% at all time points. Respondents reported that course participation increased both their comfort (10% pre vs. 89% post-training, pConclusion: A combined simulation and web-based training course increased comfort and willingness to use BB and was associated with increased utilization of this technique for forearm fracture reduction in the PED.

Objectives Fracture pain in the pediatric emergency department generally is treated with systemic analgesia using opioids. Fracture pain can alternatively be controlled with ultrasound (U/S)-guided nerve blocks for which only minimal training is available to pediatric emergency medicine physicians. This study evaluated the effects of a Web- and half-day simulation-based U/S course. Outcome measures were physician comfort level with and intention to use U/S-guided nerve blocks in clinical practice. Methods We conducted a presurvey and postsurvey study targeting pediatric emergency medicine physicians. Participants completed a Web-based tutorial and a half-day simulation program. Participants completed survey questionnaires to document their comfort level and intention to use U/S-guided nerve blocks. Questionnaires were completed before, immediately after, and 1 month after course. Results Eleven physicians participated in the study. The participants' comfort with and intention to use U/S-guided ulnar and femoral nerve blocks increased immediately after course, but neither increase was sustained 1 month after course. Immediately following the course, participants reported that the course addressed their learning needs (91%) and that they would consider advanced training (91%). One month after course, participants reported that they would partake in refresher courses (82%), particularly if offered once per year (64%). Conclusions This study suggests that Web- and simulation-based learning can increase comfort and intention to use U/S-guided nerve blocks and the need for follow-on training. Participants reported that their learning needs were met but that they would need annual refresher courses.