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Untreated pain in childhood may have ramifications well into adulthood. Opioid medications have an important role in care for moderate to severe pain that cannot be relieved by first-line interventions, but clinicians must approach opioid use in the emergency department in an evidence-based, socially responsible manner. This issue reviews evidence-based approaches to with a focus on optimizing nonopioid pain management as a first approach and using opioid medications safely, when appropriate. Recommendations are provided for safer opioid prescribing, including assessment of risk factors for opioid misuse, careful family counseling and education, and suggested prescribing limits. Prescription and use of naloxone in the emergency department and as take-home kits are also discussed.

Introduction: After discharge from the emergency department (ED), pain management challenges parents, who have been shown to undertreat their children’s pain. Our goal was to evaluate the effectiveness of a five-minute instructional video for parents on pain treatment in the home setting to address common misconceptions about home pediatric pain management. Methods: We conducted a randomized, single-blinded clinical trial of parents of children ages 1-18 years who presented with a painful condition, were evaluated, and were discharged home from a large, tertiary care pediatric ED. Parents were randomized to a pain management intervention video or an injury prevention control video. The primary outcome was the proportion of parents that gave their child pain medication at home after discharge. These data were recorded in a home pain diary and analyzed using the chi square test to determine significant difference. Parents’ knowledge about components of at-home pain treatment were tested before, immediately following, and two days after intervention. We used McNemar’s test statistic to compare incorrect pretest/correct post-test answers between intervention and control groups. Results: A total of 100 parents were enrolled: 59 parents watched the pain education video, and 41 the control video. Overall, 75% of parents completed follow-up, providing information about home medication use. Significantly more parents provided pain medication to their children after watching the educational video: 96% vs 80% (difference 16%; 95% CI 7.8-31.3%). Significantly more parents had correct pain treatment knowledge immediately following the educational video about pain scores (P = 0.04); the positive effects of analgesics (P

Purpose Clean catch urine samples may be an alternative specimen to test for chlamydia and gonorrhea infections. The aim of this study was to determine the sensitivity and specificity of clean urine for chlamydia and gonorrhea in women. Methods This was a noninferiority prospective cohort study of women aged 14–22 years requiring chlamydia and gonorrhea testing. Patients provided a vaginal swab (gold standard), clean urine (test sample), and dirty urine (usual care). All samples were analyzed using Hologic's Aptima Combo2 Assay, a second-generation nucleic acid amplification test. The sensitivity and specificity of the clean and dirty urine were calculated and compared. Results Three hundred and twenty-three females were included, mean age 17.0 ± 1.6 years. For chlamydia, 59 participants were positive by vaginal swab. The sensitivity of clean urine to diagnose chlamydia was 86.2% (95% CI: 74.8%–93.1%) and specificity was 98.8% (95% CI: 96.5%–99.8%). The sensitivity of dirty urine to diagnose chlamydia was 89.8% (95% CI: 79.2%–95.6%), and the specificity was 99.6% (95% CI 97.6%–100%). For gonorrhea, 18 participants were positive by vaginal swab. The sensitivity of clean urine to diagnose gonorrhea was 94.4% (95% CI: 72.4%–100%) and specificity was 99.7% (95% CI: 98.0%–100.0%). The sensitivity of dirty urine to diagnose gonorrhea was 100% (95% CI: 79.3%–100%) and specificity was 99.7% (95% CI: 98.0%–100%). Specificity of clean urine was noninferior compared with dirty urine for diagnosing chlamydia (p = .0004) and gonorrhea (p Conclusions Clean urine samples may be an alternative option to diagnose chlamydia and gonorrhea in women.

Background Fractures are a common childhood injury. Although the pain associated with fractures is well described, the related functional impact is less understood. When a child's function is impaired, his or her ability to participate in day-to-day life is restricted. Eighty percent of children with fractures experience compromise in daily function. An in-depth understanding of function can guide emergency department (ED) providers' discharge instructions. Objectives Our aim was to report caregivers' perspectives of the functional impact of limb fractures on their children's day-to-day life activities. Methods We performed a qualitative study using interviews of caregivers of children (aged 5 to 11 years) who received care for acute, nonoperative long bone fractures in a pediatric ED. Audio-recorded, semistructured telephone interviews were completed 7 to 14 days after the ED visit. Interviews were primarily open ended, including questions targeting areas of function from existing pediatric fracture literature. Qualitative analysis was completed using content analysis. Results Twenty-five interviews were included in the final analysis. Most of the children were diagnosed with upper extremity fractures, and most participants were mothers. All parents reported a change in their child's function. The most commonly affected areas were sleep, activities of daily living, and play. Play was either self-limited by the child or restricted by the parent. Pain was worse in the first days after discharge. Many children struggled emotionally with functional limitations. All children required help from their parents to perform daily tasks; this required adaptive strategies such as planning, changes to household routine, and missed work. Key concerns from parents included regression in the child's independence and fracture healing and complications. Conclusions Function is universally impaired in young children with fractures, significantly affecting family life after discharge. Discharge conversations with families should include pain management, changes to activities of daily living, family routines and play, and expectations for fracture healing.

The aim of this study was to prospectively investigate the role of near-infrared spectroscopy (NIRS) in identifying pediatric trauma patients who required lifesaving interventions (LSIs).Prospective cohort study of children age 0 to 18 years who activated the trauma team response between August 15, 2017, and February 12, 2019, at a large, urban pediatric emergency department (ED).The relationship between the lowest somatic NIRS saturation and the need for LSIs (based on published consensus definition) was investigated. Categorical variables were analyzed by χ 2 test, and continuous variables were analyzed by Student t test.A total of 148 pediatric trauma patients had somatic NIRS monitoring and met the inclusion criteria. Overall, 65.5% were male with a mean ± SD age of 10.9 ± 6.0 years. Injuries included 67.6% blunt trauma and 28.4% penetrating trauma with mortality of 3.4% (n = 5). Overall, the median lowest somatic NIRS value was 72% (interquartile range, 58%-88%; range, 15%-95%), and 43.9% of patients had a somatic NIRS value70%. The median somatic NIRS duration recorded was 11 minutes (interquartile range, 7-17 minutes; range, 1-105 minutes). Overall, 36.5% of patients required a LSI including 53 who required a lifesaving procedure, 17 required blood products, and 17 required vasopressors. Among procedures, requiring a thoracostomy was significant.Pediatric trauma patients with a somatic NIRS value70% had a significantly increased odds of requiring a LSI (odds ratio, 2.11; 95% confidence interval, 1.07-4.20). Somatic NIRS values70% had a sensitivity and specificity of 56% and 63%, respectively.Pediatric trauma patients with somatic NIRS values70% within 30 minutes of ED arrival have an increased odds of requiring LSIs. Among LSIs, pediatric trauma patients requiring thoracostomy was significant. The role of NIRS in incrementally improving the identification of critically injured children in the ED and prehospital setting should be evaluated in larger prospective multicenter studies.

BACKGROUND Adolescents and young adults account for half of the 20 million new cases of sexually transmitted infections each year. Expedited partner therapy (EPT) has been shown to decrease reinfection rates and is recommended by the Centers for Disease Control and Prevention. We aimed to (1) assess adolescents' awareness of EPT, (2) assess their likelihood of giving EPT received in the pediatric emergency department (PED) to their partner(s), and (3) identify factors associated with increased likelihood of giving EPT to their partner(s). METHODS Adolescents and young adults aged 14 to 22 years seeking care in 2 PEDs participated in a survey. Main outcomes were EPT awareness and likelihood of giving EPT to his/her partner(s). Patients were dichotomized into likely and not likely to provide partner(s) with EPT based on answers to a 5-point Likert scale question. χ and t tests were used to analyze the data. RESULTS Three hundred ninety-three participants were included. Only 11% (n = 42) were aware of EPT; however, 80% (n = 316) reported to be likely to give EPT received in the PED to his/her partner(s). Study site, being sexually active, and engaging in high-risk sexual behaviors were associated with an increased likelihood of giving EPT to their partner(s) (P < 0.05). CONCLUSIONS Many adolescents are not aware of EPT; however, most were theoretically likely to give EPT received in the PED to his/her partner(s). With increasing rates of sexually transmitted infections and high utilization of the PED for adolescent reproductive health services, efforts to incorporate the use of EPT in PED workflows would be beneficial.

Objective To measure the variability in discharge opioid prescription practices for children discharged from the emergency department (ED) with a long-bone fracture. Design A retrospective cohort study of pediatric ED visits in 2015. Setting Four pediatric EDs. Subjects Children aged four to 18 years with a long-bone fracture discharged from the ED. Methods A multisite registry of electronic health record data (PECARN Registry) was analyzed to determine the proportion of children receiving an opioid prescription on ED discharge. Multivariable logistic regression was performed to determine characteristics associated with receipt of an opioid prescription. Results There were 5,916 visits with long-bone fractures; 79% involved the upper extremity, and 27% required reduction. Overall, 15% of children were prescribed an opioid at discharge, with variation between the four EDs: A = 8.2% (95% confidence interval [CI] = 6.9–9.7%), B = 12.1% (95% CI = 10.5–14.0%), C = 16.9% (95% CI = 15.2–18.8%), D = 23.8% (95% CI = 21.7–26.1%). Oxycodone was the most frequently prescribed opioid. In the regression analysis, in addition to variation by ED site of care, age 12–18 years, white non-Hispanic, private insurance status, reduced fracture, and severe pain documented during the ED visit were associated with increased opioid prescribing. Conclusions For children with a long-bone fracture, discharge opioid prescription varied widely by ED site of care. In addition, black patients, Hispanic patients, and patients with government insurance were less likely to be prescribed opioids. This variability in opioid prescribing was not accounted for by patient- or injury-related factors that are associated with increased pain. Therefore, opioid prescribing may be modifiable, but evidence to support improved outcomes with specific treatment regimens is lacking.

Racial disparities and differences exist in emergency care. Obtaining a sexual history is standard of care for adolescents with abdominal pain. Testing for sexually transmitted infections (STIs) and pregnancy should be based on historical findings. The objective of this study was to determine whether differential care was provided to adolescent female patients with abdominal pain based on patient race or healthcare provider characteristics by evaluating the documentation of sexual history, STI testing, and pregnancy testing.This was a retrospective chart review of female patients between the ages of 14 and 18 years with abdominal pain presenting to a pediatric emergency department. Patient and provider characteristics, sexual history documentation, STI, and pregnancy testing were abstracted. Data were analyzed using χ 2 test and logistic regression model.Eight hundred eighty-six encounters were included in the analysis. Median patient age was 16 years (range, 14-18 years); 359 (40.5%) were non-White. Differential care was provided. Non-White patients compared with White patients were more likely to have a documented sexual history (59.9% vs 44.0%, P0.001), STI testing (24.8% vs 7.8%, P0.001), and pregnancy testing (76.6% vs 66.2%, P0.001). Among sexually active female patients, the racial disparity for STI testing persisted ( P = 0.010). Provider type and sex did not result in differences in sexual history documentation, STI, or pregnancy testing for non-White compared with White patients ( P0.05).Differential care was provided to non-White adolescents with abdominal pain compared with White adolescents. They were more likely to have a documented sexual history, STI testing, and pregnancy testing. Healthcare provider characteristics did not impact patient care. This racial disparity resulted in better medical care for non-White adolescents, but this may be the consequence of underlying implicit bias.

Objectives: Intranasal dexmedetomidine is a potentially effective anxiolytic but its role in pediatric laceration repair is only emerging. Future trials and clinical adoption of intranasal dexmedetomidine depend on understanding pediatric emergency providers’ practice patterns surrounding anxiolysis and perceived barriers to intranasal dexmedetomidine for anxiolysis during suture repair in children. Our objectives were to characterize these parameters to inform future research and facilitate clinical adoption. Methods: We conducted an online survey of pediatric emergency physician members of Pediatric Emergency Research Canada from September to December 2020. Questions pertained to perceptions of anxiolysis for suture repair, with a focus on intranasal dexmedetomidine. The primary outcome was anxiolysis for suture repair. Data were reported using descriptive statistics. Results: The response rate was 155/225 (68.9%). During suture repair, 127/148 (86%) believed that > 25% of young children experience distress requiring physical restraint. 116/148 (78%) would provide anxiolysis, mainly intranasal benzodiazepines (100/148, 68%). Only 6/148 (4%) would provide intranasal dexmedetomidine but 95/148 (64%) would consider it if there was evidence of benefit. The most common perceived barriers to intranasal dexmedetomidine included inadequate personal experience (114/145, 79%) and lack of access (60/145, 41%). Conclusions: Most Canadian pediatric emergency providers believe that laceration repair in a young child is distressing. Despite questionable efficacy, most would provide intranasal benzodiazepines, but would consider intranasal dexmedetomidine if there was evidence of benefit.

* Abbreviations: aOR — : adjusted odds ratio CI — : confidence interval ED — : emergency department RR — : relative reduction Pain caused by long bone fractures is a common reason for opioid prescribing in the emergency department (ED) setting.1 Approximately 40% of opioid overdose deaths involve a prescription,2 and in response, opioid prescribing has declined in the last decade.3 We previously demonstrated racial and/or ethnic disparities in the ED management of pain among children with long bone fractures.4 We now perform this study to investigate whether racial and/or ethnic differences in provision of outpatient opioid prescriptions for children discharged from the ED with long bone fractures have attenuated over time. We performed a retrospective cross-sectional study of children aged 4 to

Primary Subject area Emergency Medicine - Paediatric Background Fractures occur in up to half of children by age 16 years. After initial emergency care for a fracture, function is universally impaired in children, and impacts extend to the immediate family. Knowledge of expected functional limitations is key to providing proper discharge instructions and anticipatory guidance to families. Objectives Our study objectives were to understand: 1) how adolescents (12-17 years) describe the functional impact of fractures on their lives; 2) how adolescents’ reports of their experiences compare to those of their caregivers; and 3) the impact of the fracture on the family unit. Design/Methods We conducted individual, semi-structured interviews from June 2019 to November 2020 with adolescents and their caregivers, 7-14 days following their initial visit to a pediatric emergency department. We utilized qualitative content analysis methodology. Recruitment proceeded until thematic saturation was achieved. Coding and analysis were concurrent with recruitment and interviews. A secondary coder reviewed 40% of the transcripts, and the coding team met regularly to discuss the coding framework and key themes. The interview script was modified in an iterative process, to reflect emerging themes. Results We completed a total of 29 interviews. The most commonly affected functions were: a) showering and hygiene (which required the most caregiver support); b) sleep variability (due to pain and cast-related discomfort); and c) exclusion from sports/activities. Many adolescents experienced disruptions to social activities and gatherings. Adolescents valued independence and often chose to take more time to complete a task to preserve this, regardless of inconvenience. Both adolescents and caregivers reported feelings of frustration as a result of day-to-day impacts imposed by the injury. Generally, caregivers’ perspectives were in keeping with the experiences that adolescents described for themselves. Notable family impacts included what we described as ‘sibling burden’ or conflicts that arose when a sibling had to take on extra chores/tasks. Conclusion These themes highlight an opportunity to better tailor discharge instructions for adolescents with fractures. Key messages include: 1) expect pain and impaired sleep, especially in the first few days; 2) allow extra time to complete tasks independently, especially for grooming and hygiene; 3) consider family impact, especially sibling burden; 4) prepare for changes in activities and social dynamics; and 5) frustration is normal, for both adolescents and caregivers. Future work can focus on developing a novel, family-informed tool to assess functional outcomes following injury.

CONTEXT Opioid-related harms continue to rise for children and youth. Analgesic prescribing decisions are challenging because the risk for future nonmedical opioid use or disorder is unclear. OBJECTIVE To synthesize research examining the association between short-term therapeutic opioid exposure and future nonmedical opioid use or opioid use disorder and associated risk factors. DATA SOURCES We searched 11 electronic databases. STUDY SELECTION Two reviewers screened studies. Studies were included if: they were published in English or French, participants had short-term (≤14 days) or an unknown duration of therapeutic exposure to opioids before 18 years, and reported opioid use disorder or misuse. DATA EXTRACTION Data were extracted, and methodologic quality was assessed by 2 reviewers. Data were summarized narratively. RESULTS We included 21 observational studies (49 944 602 participants). One study demonstrated that short-term therapeutic exposure may be associated with opioid abuse; 4 showed an association between medical and nonmedical opioid use without specifying duration of exposure. Other studies reported on prevalence or incidence of nonmedical use after medical exposure to opioids. Risk factors were contradictory and remain unclear. LIMITATIONS Most studies did not specify duration of exposure and were of low methodologic quality, and participants might not have been opioid naïve. CONCLUSIONS Some studies suggest an association between lifetime therapeutic opioid use and nonmedical opioid use. Given the lack of clear evidence regarding short-term therapeutic exposure, health care providers should carefully evaluate pain management options and educate patients and caregivers about safe, judicious, and appropriate use of opioids and potential signs of misuse.

Background Given the current opioid crisis, caregivers have mounting fears regarding the use of opioid medication in their children. We aimed to determine caregivers’ a) willingness to accept, b) reasons for refusing, and c) past experiences with opioids. Methods A novel electronic survey of caregivers of children aged 4 to 16 years who had an acute musculoskeletal injury and presented to two Canadian paediatric emergency departments (ED) (March to November 2017). Primary outcome was caregiver willingness to accept opioids for moderate pain for their children. Results Five hundred and seventeen caregivers participated; mean age was 40.9 (SD 7.1) years with 70.0% (362/517) mothers. Children included 62.2% (321/516) males with a mean age of 10.0 (SD 3.6) years. 49.6% of caregivers (254/512) reported willingness to accept opioids for ongoing moderate pain in the ED, while 37.1% (190/512) were ‘unsure’; 33.2% (170/512) of caregivers would accept opioids for at-home use, but 45.5% (233/512) were ‘unsure’. Caregivers’ primary concerns were side effects, overdose, addiction, and masking of diagnosis. Caregiver fear of addiction (odds ratio [OR] 1.12, 95% confidence interval [CI] 1.01 to 1.25) and side effects (OR 1.25, 95% CI 1.11 to 1.42) affected willingness to accept opioids in the emergency department; fears of addiction (OR 1.19, 95% CI 1.07 to 1.32), and overdose (OR 1.15, 95% CI 1.04 to 1.27) affected willingness to accept opioids for at-home use. Conclusions Only half of the caregivers would accept opioids for moderate pain, despite ongoing pain following nonopioid analgesics. Caregivers’ fears of addiction, side effects, overdose, and masking diagnosis may have influenced their responses. These findings are a first step in understanding caregiver analgesic decision making.

Objectives Approximately 40% of children and adolescents with chronic pain report at least 1 dismissal experience, citing medical providers and parents as the primary and most distressing dismissers. Previous research indicates sex differences in pain dismissal experience and observer pain perception. This study examined parental reactions to dismissive provider-child scenarios and the influence of provider and patient sex on perceptions. Methods Community parents (N=326) completed an online survey. Parents were randomized to listen to 1 of 8 vignettes of a provider-child chronic pain scenario. Vignettes varied by type of scenario (appropriate vs. dismissive)×provider sex×patient sex. Results Overall, parents rated the dismissive scenario more negatively. There was a significant interaction between provider sex and scenario regarding likelihood to bring their own child to this provider and a significant 3-way interaction regarding provider belief of the pain complaint. When asked how they would feel if this was their own child, parents who heard the dismissive scenario reported more negative reactions. When asked what they would say to the provider, parents in the dismissive condition were more likely to defend their child and request a second opinion. Discussion Parents consistently identified the dismissive language in a child and provider scenario. Female providers and sex-matched dyads seem to be more polarizing in terms of likelihood to bring their child to the provider and belief of pain, respectively. Providers within these groups may need to be especially cautious with their language when responding to pediatric chronic pain complaints.

OBJECTIVES: Academic emergency departments (ED) rely on a steady flow of patients to provide residents with good clinical training. Understanding institutional volume patterns allows training directors to create a schedule that maximizes learning opportunities while also adequately staffing the ED. Our primary objective of this study was to utilize heat‐mapping software to optimize resident staffing in an academic ED. METHODS: Heat‐mapping tools within Microsoft Excel were utilized to overlay ED patient arrival patterns on top of the potential patients per hour based on published productivity data for trainees and historical averages for advanced practice providers at our institution. Time frames for under‐ and overstaffing were identified and color‐coded. This analysis informed a revised schedule template and the same heat‐mapping process was used to determine the appropriateness of the revised staffing template. RESULTS: The heat map for the original schedule template revealed understaffing in the morning and overstaffing the rest of the day. Informed by these findings, schedule adjustments were made. There was no net increase in the number of resident or advanced practice provider coverage hours. Prior to implementation, the ED was understaffed by 5% or more during 18.4% of operating hours. Following changes to the staffing template, only 5.9% of operating hours were understaffed (p

Introduction Vaccine hesitancy and delays in vaccine administration time have limited the success of prior influenza vaccination initiatives in the pediatric emergency department (ED). In 2018-2019, season 1, this ED implemented mandatory vaccine screening and offered the vaccine to all eligible patients; however, only 9% of the eligible population received the vaccine. In 2019-2020, season 2, the team sought to improve influenza vaccination rates from 9% to 15% and administer over 2,000 vaccines to eligible ED patients. Methods Key drivers included: identifying vaccine hesitancy, providing counseling, reducing administration delays, and developing reminders for vaccine administration. We tested interventions using plan-do-study-act cycles. We included discharged ED patients, age 6 months-18 years old, emergency severity index score 2-5, and no prior vaccine this season. Process measures included percent of patients screened, eligible, accepting the vaccine, and leaving before vaccination. Outcome measures were the percent of eligible patients vaccinated and the total number of vaccines administered. Vaccination time was the balancing measure. Results We included 57,804 children in this study. Comparing season 1 to 2, screening rates (84%) and eligibility rates (58%) were similar. Vaccine acceptance rates improved from 13% to 22%, the proportion of patients leaving before vaccination decreased from 32% to 17%, and vaccination rates improved from 9% to 20%. Total vaccines administered increased from 1,309 to 3,180, and vaccination time was 5 minutes faster in season 2. Conclusions This ED influenza vaccination process provides a model to overcome vaccine hesitancy and can be adapted and replicated for any vaccine-preventable illness.

Objective To compare the effectiveness and safety of prescribing ibuprofen and oxycodone for at-home management of children’s fracture pain. Methods A prospective observational cohort was conducted at the Stollery Children’s Hospital pediatric emergency department (June 2010-July 2014). Children aged 4–16 years with an isolated fracture discharged home with advice to use either ibuprofen or oxycodone were recruited. Results A cohort of 329 children (n = 217 ibuprofen, n = 112 oxycodone) were included. Mean age was 11.1 years (SD 3.5); 68% (223/329) were male. Fracture distribution included 80.5% (264/329) upper limb with 34.3% (113/329) requiring fracture reduction. The mean reduction in Faces Pain Score-Revised score (maximum pain–post-treatment pain) for Day 1 was 3.6 (SD 1.9) (ibuprofen) and 3.8 (SD 2.1) (oxycodone) (p = 0.50); Day 2 was 3.6 (SD 1.8) (ibuprofen) and 3.7 (SD 1.6) (oxycodone) (p = 0.56); Day 3 was 3.7 (SD 1.7) (ibuprofen) and 3.3 (SD 1.7) (oxycodone) (p = 0.24). Children prescribed ibuprofen (51.2%, 109/213) experienced less adverse events compared to those prescribed oxycodone (70.5% 79/112) on Day 1 (p = 0.001). Children prescribed ibuprofen (71.8%, 150/209) had their function (eat, play, school, sleep) affected less than those prescribed oxycodone (83.0%, 93/112) (p = 0.03) on Day 1. Conclusion Children prescribed ibuprofen or oxycodone experienced similar analgesic effectiveness for at-home fracture pain. Oxycodone prescribing was associated with more adverse events and negatively impacted function. Oxycodone use does not appear to confer any benefit over ibuprofen for pain relief and has a negative adverse effect profile. Ibuprofen appears to be a safe option for fracture-related pain.

Adolescents and young adults account for half of the 20 million new cases of sexually transmitted infections each year. Expedited partner therapy (EPT) has been shown to decrease reinfection rates and is recommended by the Centers for Disease Control and Prevention. We aimed to (1) assess adolescents' awareness of EPT, (2) assess their likelihood of giving EPT received in the pediatric emergency department (PED) to their partner(s), and (3) identify factors associated with increased likelihood of giving EPT to their partner(s).Adolescents and young adults aged 14 to 22 years seeking care in 2 PEDs participated in a survey. Main outcomes were EPT awareness and likelihood of giving EPT to his/her partner(s). Patients were dichotomized into likely and not likely to provide partner(s) with EPT based on answers to a 5-point Likert scale question. χ and t tests were used to analyze the data.Three hundred ninety-three participants were included. Only 11% (n = 42) were aware of EPT; however, 80% (n = 316) reported to be likely to give EPT received in the PED to his/her partner(s). Study site, being sexually active, and engaging in high-risk sexual behaviors were associated with an increased likelihood of giving EPT to their partner(s) (P0.05).Many adolescents are not aware of EPT; however, most were theoretically likely to give EPT received in the PED to his/her partner(s). With increasing rates of sexually transmitted infections and high utilization of the PED for adolescent reproductive health services, efforts to incorporate the use of EPT in PED workflows would be beneficial.

In 2008, the Pediatric Initiative on Methods, Measurement, and Pain Assessment in Clinical Trials (PedIMMPACT) published a consensus statement that recognized the dearth of research surrounding the topic of children’s satisfaction with acute pain management. This review of published literature will summarize what is known about the topic of children’s satisfaction with pain management, identify current gaps in the knowledge, and provide direction for future research in this critical area. Including children in the decision-making process as soon as they are developmentally able is a concept that is the fundamental basis for seeking assent and more active roles within healthcare decisions for children. It is the responsibility of adults to provide them with increasing opportunities for self-evaluation and more independent management of their healthcare, encouraging the development of children into adults. As clinicians and researchers, it is our prerogative to support the maturation of children by building effective methods to communicate their satisfaction with acute pain treatment and healthcare. Children’s satisfaction with acute pain management is not well studied and further research is needed for the development of inclusive, developmentally appropriate measures of satisfaction for our pediatric patients.

Objective This study aimed to validate a novel, three faced, colour-coded, action-oriented tool: The Stoplight Pain Scale (SPS). Methods A prospective observational cohort study was conducted at a Canadian paediatric emergency department from November 2014 to February 2017. Patients aged 3 to 12 years and their caregivers were asked to rate pain using the SPS and the Faces Pain Scale-Revised (FPS-R). Pain was measured just before analgesia administration, 30 minutes after analgesia administration, and immediately following a painful procedure. Results A total of 227 patients were included; 26.9% (61/227) were 3 to 5 years old while 73.1% (166/227) were 6 to 12 years old. Using Cohen’s κ, agreement for SPS and FPS-R was ‘fair’ for children (0.28 [95% confidence interval {CI} 0.20 to 0.36]) and ‘poor’ for caregivers (0.14 [95% CI 0.07 to 0.21]), at initial measurement. The SPS had ‘fair’ agreement between child and caregiver scores, (0.37 [95% CI 0.27 to 0.47]), compared to FPS-R which showed ‘poor’ agreement (0.20 [95% CI 0.12 to 0.29]). Absolute agreement between child and caregiver SPS scores improved with repeat exposure; 30 minutes after analgesia administration, caregivers and children had fair agreement (κ=0.38, 95% CI 0.28 to 0.48); they had moderate agreement directly following painful procedures (κ=0.46, 95% CI 0.34 to 0.59). Overall, 72.4% (139/192) of children and 60.2% (118/196) of caregivers preferred SPS over FPS-R. Conclusion The SPS demonstrates fair agreement with FPS-R for children and fair-moderate agreement between children and caregivers; agreement improved with repeat use. The SPS is simple and easy to use; it may have a role in empowering direct child and family involvement in pain management.

Supplemental Digital Content is available in the text., Introduction: Annual influenza vaccination is recommended for all US children 6 months and older to prevent morbidity and mortality. Despite these recommendations, only ~50% of US children are vaccinated annually. Influenza vaccine administration in the pediatric emergency department (ED) is an innovative solution to improve vaccination rates. However, during the 2017–2018 influenza season, only 75 influenza vaccinations were given in this tertiary care ED. We aimed to increase the number of influenza vaccines administered to ED patients from 75 to 1,000 between August 2018 and March 2019.s Methods: Process mapping identified potential barriers and solutions. Key interventions included mandatory vaccine screening, creation of a vaccine administration protocol, education for family, provider, and nursing, a revised pharmacy workflow, and weekly staff feedback. Interventions were tested using plan-do-study-act cycles. The process measure was the percent of patients screened for vaccine status. The primary outcome was the number of influenza vaccines administered. The balancing measures were ED length of stay (LOS), wasted vaccines, and financial impact on the institution. Results: We included 33,311 children in this study. Screening for vaccine status improved from 0% to 90%. Of those screened, 58% were eligible for vaccination, and 8.5% of eligible patients were vaccinated in the ED. In total, 1,323 vaccines were administered with no significant change in ED LOS (139 min) and no lost revenue to the hospital. Conclusions: We implemented an efficient, cost-effective, influenza vaccination program in the pediatric ED and successfully increased vaccinations in a population that might not otherwise receive the vaccine.

IntroductionMusculoskeletal (MSK) injuries are a frequent cause for emergency department (ED) visits in children. MSK injuries are associated with moderate-to-severe pain in most children, yet recent research confirms that the management of children’s pain in the ED remains inadequate. Clinicians are seeking better oral analgesic options for MSK injury pain with demonstrated efficacy and an excellent safety profile. This study aims to determine the efficacy and safety of adding oral acetaminophen or oral hydromorphone to oral ibuprofen and interpret this information within the context of parent/caregiver preference.Methods and analysisUsing a novel preference-informed complementary trial design, two simultaneous trials are being conducted. Parents/caregivers of children presenting to the ED with acute limb injury will be approached and they will decide which trial they wish to participate in: an opioid-inclusive trial or a non-opioid trial. Both trials will follow randomised, double-blind, placebo-controlled, superiority-trial methodology and will enrol a minimum of 536 children across six Canadian paediatric EDs. Children will be eligible if they are 6 to 17 years of age and if they present to the ED with an acute limb injury and a self-reported verbal Numerical Rating Scale pain score ≥5. The primary objective is to determine the effectiveness of oral ibuprofen+oral hydromorphone versus oral ibuprofen+oral acetaminophen versus oral ibuprofen alone. Recruitment was launched in April 2019.Ethics and disseminationThis study has been approved by the Health Research Ethics Board (University of Alberta), and by appropriate ethics boards at all recruiting centres. Informed consent will be obtained from parents/guardians of all participants, in conjunction with assent from the participants themselves. Study data will be submitted for publication regardless of results. This study is funded through a Canadian Institutes of Health Research grant.Trial registration numberNCT03767933, first registered on 07 December 2018.

OBJECTIVES: To test the hypotheses that minority children with long-bone fractures are less likely to (1) receive analgesics, (2) receive opioid analgesics, and (3) achieve pain reduction. METHODS: We performed a 3-year retrospective cross-sectional study of children RESULTS: In 21 069 visits with moderate-to-severe pain, 86.1% received an analgesic and 45.4% received opioids. Of 8533 patients with reassessment of pain, 89.2% experienced ≥2-point reduction in pain score and 62.2% experienced optimal pain reduction. In multivariable analyses, minority children, compared with non-Hispanic (NH) white children, were more likely to receive any analgesics (NH African American: adjusted odds ratio [aOR] 1.72 [95% confidence interval 1.51–1.95]; Hispanic: 1.32 [1.16–1.51]) and achieve ≥2-point reduction in pain (NH African American: 1.42 [1.14–1.76]; Hispanic: 1.38 [1.04–1.83]) but were less likely to receive opioids (NH African American: aOR 0.86 [0.77–0.95]; Hispanic: aOR 0.86 [0.76–0.96]) or achieve optimal pain reduction (NH African American: aOR 0.78 [0.67–0.90]; Hispanic: aOR 0.80 [0.67–0.95]). CONCLUSIONS: There are differences in process and outcome measures by race and ethnicity in the emergency department management of pain among children with long-bone fractures. Although minority children are more likely to receive analgesics and achieve ≥2-point reduction in pain, they are less likely to receive opioids and achieve optimal pain reduction.

BACKGROUND: In the midst of the current opioid crisis, physicians are caught between balancing children's optimal pain management and the risks of opioid therapy. This study describes pediatric emergency physicians' practice patterns for prescribing, knowledge and attitudes regarding, and perceived barriers to and facilitators of short-term use of opioids. METHODS: We created a survey tool using published methodology guidelines and distributed it from October to December 2017 to all physicians in the Pediatric Emergency Research Canada database using Dillman's tailored design method for mixed-mode surveys. We performed bivariable binomial logistic regressions to ascertain the effects of clinically significant variables (e.g., training, age, sex, degree of worry regarding severe adverse events) on use of opioids as a first-line treatment for moderate pain in the emergency department, and prescription of opioids for moderate or severe pain for at-home use in children. RESULTS: Of the 224 physicians in the database, 136 (60.7%) completed the survey (60/111 [54.1%] women; median age 44 yr). Of the 136, 74 (54.4%) had subspecialty training. Intranasally administered fentanyl was the most commonly selected opioid for first-line treatment of moderate (47 respondents [34.6%]) and severe (82 [60.3%]) pain due to musculoskeletal injury. On a scale of 0 (not worried) to 100 (extremely worried), physicians' median score for worry regarding physical dependence was 6.0 (25th percentile 0.0, 75th percentile 16.0), for worry regarding addiction 10.0 (25th percentile 2.0, 75th percentile 20.0) and for worry regarding diversion of opioids 24.5 (25th percentile 14.0, 75th percentile 52.0). On a scale of 0 (not at all) to 100 (extremely), the median score for influence of the opioid crisis on willingness to prescribe opioids was 22.0 (25th percentile 8.0, 75th percentile 49.0). The top 3 reported barriers to prescribing opioids were parental reluctance (57 [41.9%]), lack of clear guidelines for pediatric opioid use (35 [25.7%]) and concern about adverse effects (33 [24.3%]). Binomial logistic regression did not identify any statistically significant variables affecting use of opioids in the emergency department or prescribed for use at home. INTERPRETATION: Emergency department physicians appeared minimally concerned about physical dependence, addiction risk and the current opioid crisis when prescribing opioids to children. Evidence-based development of guidelines and protocols for use of opioids in children may improve physicians' ability to manage pain in children responsibly and adequately.

OBJECTIVE: To determine if the Mechanism of Injury Criteria of the Field Triage Decision Scheme (FTDS) are accurate for identifying children who need the resources of a trauma center. METHODS: EMS providers transporting any injured child ≤15 years, regardless of severity, to a pediatric trauma center in 3 midsized communities over 3 years were interviewed. Data collected through the interview included EMS observed physiologic condition, suspected anatomic injuries, and mechanism. Patients were then followed to determine if they needed the resources of a trauma center by reviewing their medical record after hospital discharge. Patients were considered to need a trauma center if they received an intervention included in a previously published consensus definition. Data were analyzed with descriptive statistics including positive likelihood ratios (+LR) and 95% confidence intervals (95%CI). RESULTS: 9,483 provider interviews were conducted and linked to hospital outcome data. Of those, 230 (2.4%) met the consensus definition for needing a trauma center. 1,572 enrolled patients were excluded from further analysis because they met the Physiologic or Anatomic Criteria of the FTDS. Of the remaining 7,911 cases, 62 met the consensus definition for needing a trauma center (TC). Taken as a whole, the Mechanism of Injury Criteria of the FTDS identified 14 of the remaining 62 children who needed the resources of a trauma center for a 77% under-triage rate. The mechanisms sustained were 36% fall (16 needed TC), 28% motor vehicle crash (MVC) (20 needed TC), 7% struck by a vehicle (10 needed TC)

ObjectivesThere is limited literature about physicians' adherence to 2010 Centers for Disease Control and Prevention (CDC) Sexually Transmitted Diseases Treatment Guidelines specific to specimen collection testing methods in adolescent females in the emergency setting is limited. The objectives are

Appropriate pain measurement relies on the use of valid, reliable tools. The aim of this study was to determine and compare the psychometric properties of 3 self-reported pain scales commonly used in the pediatric emergency department (ED). The inclusion criteria were children aged 6 to 17 years presenting to the ED with a musculoskeletal injury and self-reported pain scores ≥30 mm on the mechanical Visual Analogue Scale (VAS). Self-reported pain intensity was assessed using the mechanical VAS, Faces Pain Scale-Revised (FPS-R), and Colour Analogue Scale (CAS). Convergent validity was assessed by Pearson correlations and the Bland-Altman method; responsiveness to change was assessed using paired sample t tests and standardized mean responses; and reliability was estimated using relative and absolute indices. A total of 456 participants were included, with a mean age of 11.9 years ± 2.7 and a majority were boys (252/456, 55.3%). Correlations between each pair of scales were 0.78 (VAS/FPS-R), 0.92 (VAS/CAS), and 0.79 (CAS/FPS-R). Limits of agreement (95% confidence interval) were -3.77 to 2.33 (VAS/FPS-R), -1.74 to 1.75 (VAS/CAS), and -2.21 to 3.62 (CAS/FPS-R). Responsiveness to change was demonstrated by significant differences in mean pain scores among the scales (P < 0.0001). Intraclass correlation coefficient and coefficient of repeatability estimates suggested acceptable reliability for the 3 scales at, respectively, 0.79 and ±2.29 (VAS), 0.82 and ±2.07 (CAS), and 0.76 and ±2.82 (FPS-R). The scales demonstrated good psychometric properties for children with acute pain in the ED. The VAS and CAS showed a strong convergent validity, whereas FPS-R was not in agreement with the other scales.

Primary Subject area Clinical Pharmacology and Toxicology Background Genomic variation impacts drug pharmacokinetics for commonly used children’s pain medications such as oxycodone and ibuprofen. In order to personalize and best treat children’s pain, how cytochrome enzyme polymorphisms for CYP2D6, CYP3A4, and CYP2C9 impact clinical effectiveness and safety for oxycodone and ibuprofen were studied. Objectives Primary objectives were to evaluate if allelic variations of CYP2D6, CYP2C9, and CYP3A4 would a) alter clinical effectiveness of ibuprofen and oxycodone for pain relief, and b) impact the occurrence of adverse events. Secondary objectives were to determine the degree to which these genetic and other clinical factors influence analgesic effectiveness and safety. Design/Methods This prospective, observational cohort included children aged 4-16 years who were seen in a pediatric emergency department (between June 2010 - July 2014) with an acute fracture and used ibuprofen OR oxycodone for at-home pain management. Saliva samples were obtained prior to discharge, and daily telephone follow-up collected self-reported pain scores, medication use, adverse events, and functional limitations for 3 days. Genotyping identified allelic variants of CYP2D6, CYP3A4, and CYP2C9. Pain was measured using the Faces Pain Scale-Revised. CYP2D6 metabolic phenotypes were determined based on identified variants. Regression analyses were employed to determine relationships between clinical and genomic patient characteristics, pain relief, and adverse events. Results We included 210 children (n=140 ibuprofen, n=70 oxycodone); mean age was 11.1 (±3.5) years, 66.2% were male, and 79.5% self-identified as Caucasian. The median pain reduction in the ibuprofen group was 4 (±2.0) and 4 (±3.5) in the oxycodone group on Day 1 (p = 0.69). Adverse events were experienced by 53.2% of the ibuprofen group and 78.3% of the oxycodone group (p < 0.001). CYP2D6 Intermediate Metabolizers had significantly less pain relief using oxycodone than Extensive Metabolizers (p = 0.04). CYP3A4 variants did not significantly impact pain relief or adverse events. Those with the decreased functioning CYP2C9*2 allele experienced less adverse events compared to the normal functioning allele CYP2C9*1 (p = 0.003) when using ibuprofen. Males (p = 0.035) and all children using non-pharmacological pain strategies (p = 0.02) experienced less pain relief with oxycodone. Conclusion A better understanding of pharmacogenomic variation could help personalize medication choice. Sex and non-pharmacologic pain management impact pain relief with oxycodone, warranting further study to better understand their relationship with opioid pain relief in children.

Primary Subject area Emergency Medicine - Paediatric Background Laceration repair accounts for half of procedures performed in pediatric emergency departments. Although commonly used, topical anesthetics do little to alleviate emotional distress, particularly in young children. Intranasal midazolam is frequently used but is not consistently effective. Intranasal dexmedetomidine (IND) is a new and potentially effective anxiolytic but clinical uptake is limited by a lack of pediatric data. Objectives Our objective was to understand pediatric emergency providers’ willingness, preferences, and perceived barriers surrounding anxiolysis for laceration repair in children, to inform the design of a future clinical trial of IND. Design/Methods This was an online survey of Canadian pediatric emergency providers listed in the Pediatric Emergency Research Canada database. The survey was developed according to published guidelines and featured a vignette of a 3-year-old distressed child requiring laceration repair. It was hosted on the Research Electronic Data Capture platform in English and French, and was disseminated from September to December 2020. The primary outcome was the proportion of respondents that would provide anxiolysis. Secondary outcomes included perceived barriers to IND use. Data were reported using summary statistics. Results The response rate was 155/225 (68.9%), of which 98/141 (70%) were Royal College accredited pediatric emergency physicians. For 129/147 (88%) of respondents, 80-100% of their patients were children. 123/146 (84%) had > 6 years independent practice experience and 126/146 (86%) performed > 4 laceration repairs per month. 127/148 (86%) believed that > 25% of children experienced distress significant enough to require physical restraint during laceration repair. 116/148 (78%) indicated they would provide anxiolysis, mainly as intranasal benzodiazepines, such as midazolam (100/109, 92%). 95/148 (64%) indicated that they would consider IND if evidence suggested it was effective. Common perceived barriers included inadequate personal (114/145, 79%) and nursing (109/145, 75%) experience with IND, and lack of formulary access to IND (60/145, 41%). Conclusion Most pediatric emergency providers believe that laceration repair in a young child is distressing and would provide anxiolysis. Most providers would consider IND if there was evidence of benefit, suggesting that favourable findings from a clinical trial would have good clinical uptake.

Background: Suicide is the second leading cause of death in older children. Suicide has tripled in children 10-14 years and increased by 75% in adolescents 15-19 years from 2007-2017. Because children at risk for suicide may be difficult to detect, routine screening is necessary. The emergency department (ED) is an ideal location to perform screening because adolescents who use the ED engage in risky behaviors. However, during the pre-implementation period of this study only 1% of children >11 presenting to this ED …

Optimizing acute pain treatment for children in the emergency setting is challenging. Despite the prevalence of acute pain experienced in the emergency department, health care professionals provide inconsistent and often inadequate pain treatment for children for a number of different reasons. Undertreated pain can be associated with negative consequences. This review will provide 10 practical, effective, and evidence-based interventions that can be used to reduce the pain experienced by children in the emergency department setting and beyond.

IntroductionOver 80% of children experience compromise in functioning following a fracture. Digital media may improve caregiver knowledge of managing fracture pain at home.ObjectivesTo determine whether an educational video was superior to an interactive web-based module (WBM) and verbal instructions, the standard of care (SOC).MethodsThis randomized trial included caregivers of children 0-17 years presenting to the emergency department (ED) with non-operative fractures. Primary outcome was the gain score (pre-post intervention) on a 21-item questionnaire testing knowledge surrounding pain recognition and management for children with fractures. Secondary outcomes included survey of caregiver confidence in managing pain (five-item Likert scale), number of days with difficulty sleeping, before return to a normal diet, and work/school missed.ResultsWe analyzed 311 participants (WBM 99; video 108; SOC 104) with a mean (SD) child age of 9.6 (4.2) years, of which 125/311 (40.2%) were female. The video (delta=2.3, 95% CI: 1.3, 3.3; pConclusionsA web-based module and online video are superior to verbal instructions for improving caregiver knowledge on management of children’s fracture pain without improvement in functional outcomes

In 2011, revised Field Triage Guidelines were released jointly by the Centers for Disease Control and Prevention (CDC) and the American College of Surgeons - Committee on Trauma (ACS-COT). It is unknown how the modifications will affect the number of injured children identified by EMS providers as needing transport to a trauma center.To determine the change in under- and over-triage rates when the 2011 Field Triage Guidelines are compared to the 2006 and 1999 versions.EMS providers in charge of care for injured children (15 years) transported to pediatric trauma centers in 3 mid-sized cities were interviewed immediately after completing transport. Patients were included regardless of injury severity. The interview included patient demographics and each criterion from the Field Triage Guidelines' physiologic status, anatomic injury, and mechanism of injury steps. Included patients were followed through hospital discharge. The 1999, 2006, and 2011 Guidelines were each retrospectively applied to the collected data. Children were considered to have needed a trauma center if they had non-orthopedic surgery within 24 hours, ICU admission, or died. Data were analyzed using descriptive statistics.EMS interviews were conducted for 5,610 children and outcome data was available for 5,594 (99.7%). Average age was 7.6 years; 5% of children were identified as needing a trauma center using the study outcome. Applying the 1999, 2006, or 2011 Guidelines to the EMS interview data the over-triage rate was 32.6%, 27.9%, and 28.0%, respectively. The under-triage rate was 26.5%, 35.1%, and 34.8%, respectively. The 2011 Guidelines resulted in an 8.2% (95% CI 0.6-15.9%) absolute increase in under-triage and a 4.6% (95% CI 2.8-6.3%) decrease in over-triage compared to 1999 Guidelines.Use of the Field Triage Guidelines for children resulted in an unacceptably high rate of under-triage regardless of the version used. Use of the 2011 Guidelines increased under-triage compared to the 1999 version. Research is needed to determine how to better assist EMS providers in identifying children who need the resources of a trauma center.

Background Universal administration of the influenza vaccine is the best strategy for preventing morbidity and mortality. Vaccine administration in the emergency department (ED) is an innovative approach to improving vaccination rates. However, during the 2017–2018 influenza season only 75 influenza vaccines were administered, 0.2% of the total population in this tertiary care ED. Objectives We aimed to increase the number of influenza vaccines administered from 75 to 1000 in patients discharged from the ED between September 2018 and March 2019. Methods A multidisciplinary workgroup performed process mapping to identify potential barriers and solutions. The electronic health record was engineered to facilitate our key interventions: a required influenza vaccination screening question, scripted patient education, and an influenza vaccine nursing protocol with a clinical decision support tool. Interventions were tested using plan-do-study-act cycles. Process measures included percent screened and percent requested. The primary outcome was the number of influenza vaccines administered. The balancing measure was ED length of stay. Results 33,311 ED patients met inclusion criteria. In this population, influenza vaccination screening rates improved from 0 to 90% (figure 1) and 41% of children were found to be unvaccinated. 1323 children (4%) received the influenza vaccine (figure 2). Additionally, there was no change in ED LOS (139 min). Conclusions An efficient, nurse-driven workflow that screened for vaccination status, educated parents, and then provided the influenza vaccination to children during the ED visit significantly increased the number of children receiving the influenza vaccine from 75 to 1323 without extending length of stay.

Background Early diagnosis and timely surgery are critical to treat children with testicular torsion. Only 33% of patients met the hospital goal of ‘critical diagnosis to operating room time of 60 minutes or less [CDOR60]’ prior to starting the QI project. Objectives The objective of the quality improvement project was to increase the utilization of TWIST score, a validated clinical scoring system from 0% to 80% over 12 months period for children evaluated for testicular torsion, as a means of increasing the number of patients with CDOR60. Methods Deploying the Institute for Healthcare Improvement Model for Improvement, we formulated an aim statement and identified key drivers. Of our interventions, successful implementation of the TWIST score in the emergency department (ED), with a guideline to support earlier notification of urology for high risk patients with testicular pain, was determined to be the highest impact intervention. We educated providers and gave biweekly feedback about guideline adherence, created order panels and documentation tabs in our electronic medical record to encourage documentation. Results Between September 2018 and April 2019, TWIST score documentation improved to >80% and was sustained at that rate for 4 months. After implementation of the guideline, the critical diagnosis to OR time of 60 minutes or less was achieved in 12 out of 16 patients diagnosed with testicular torsion in the ED [75%] compared to our baseline of 33%. Conclusions A quality improvement project to improve the timeliness of care for children with testicular torsion resulted in delivery of expedited surgical care for these patients.

OBJECTIVES: Hospital trauma activation criteria are intended to identify children who are likely to require aggressive resuscitation or specific surgical interventions that are time sensitive and require the resources of a trauma team at the bedside. Evidence to support criteria is limited, and no prior publication has provided historical or current perspectives on hospital practices toward informing best practice. This study aimed to describe the published variation in (1) highest level of hospital trauma team activation criteria for pediatric patients and (2) hospital trauma team membership and (3) compare these finding to the current ACS recommendations. METHODS: Using an Ovid MEDLINE In-Process & Other Non-Indexed Citations search, any published description of hospital trauma team activation criteria for children that used information captured in the prehospital setting was identified. Only studies of children were included. If the study included both adults and children, it was included if the number of children assessed with the criteria was included. RESULTS: Eighteen studies spanning 20 years and 13,184 children were included. Hospital trauma team activation and trauma team membership were variable. Nearly all (92%) of the trauma criteria used physiologic factors. Penetrating trauma (83%) was frequently included in the trauma team activation criteria. Mechanisms of injury (52%) were least likely to be included in the highest level of activation. No predictable pattern of criterion adoption was found. Only 2 of the published criteria and 1 of published trauma team membership are consistent with the current American College of Surgeons recommendations. CONCLUSIONS: Published hospital trauma team activation criteria and trauma team membership for children were variable. Future prospective studies are needed to define the optimal hospital trauma team activation criteria and trauma team membership and assess its impact on improving outcomes for children.

The objective of this study was to determine the feasibility of a comic education module in the Emergency Department setting. A convenience sample of 50 injured children and their caregivers were enrolled. The comic was found to be likeable, easy to read, and provided important information to both children and their caregivers. Total time to read the comic was three minutes (SD 1.4, range 1.4-7.1). Most children (60%) read the comic independently, including all children over age 14 years. At 72-hour phone follow-up, 86% of caregivers had accurate recall of all three comic teaching points. This innovative comic educational module is feasible for use for children ages 4-18 years in the Emergency Department. Though this comic was intended to educate children, caregivers recalled all three teaching points 72 hours after discharge.

Objective This study aims to determine the frequency that umbilical venous catheters (UVCs) and peripherally inserted central catheters (PICCs) migrate into the cardiothymic silhouette after initial verification of correct placement. Study Design This is a single-center, retrospective study in neonates in whom a PICC or UVC was placed. The frequency of catheter tip migration into the cardiothymic silhouette requiring catheter manipulation was determined radiographically at 1 and 24 hours, respectively, after insertion. Results At 1 and 24 hours, 36 and 23% of UVCs (n = 41) migrated into the cardiothymic silhouette, respectively. At 1 and 24 hours, 23 and 11% of PICCs (n = 63) migrated into the cardiothymic silhouette, respectively. Migration was not associated with birth weight, weight at insertion, or postnatal age at insertion. Conclusion UVCs and PICCs frequently migrate into the cardiothymic silhouette increase the risk for development of a pericardial effusion. Serial radiographic assessment of catheter tip location is needed to assess catheter migration within the first 24 hours of line placement.