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To estimate the impact of the PediBIRN (Pediatric Brain Injury Research Network) 4-variable clinical decision rule (CDR) on abuse evaluations and missed abusive head trauma in pediatric intensive care settings.This was a cluster randomized trial. Participants included 8 pediatric intensive care units (PICUs) in US academic medical centers; PICU and child abuse physicians; and consecutive patients with acute head injures3 years (n = 183 and n = 237, intervention vs control). PICUs were stratified by patient volumes, pair-matched, and randomized equally to intervention or control conditions. Randomization was concealed from the biostatistician. Physician-directed, cluster-level interventions included initial and booster training, access to an abusive head trauma probability calculator, and information sessions. Outcomes included "higher risk" patients evaluated thoroughly for abuse (with skeletal survey and retinal examination), potential cases of missed abusive head trauma (patients lacking either evaluation), and estimates of missed abusive head trauma (among potential cases). Group comparisons were performed using generalized linear mixed-effects models.Intervention physicians evaluated a greater proportion of higher risk patients thoroughly (81% vs 73%, P = .11) and had fewer potential cases of missed abusive head trauma (21% vs 32%, P = .05), although estimated cases of missed abusive head trauma did not differ (7% vs 13%, P = .22). From baseline (in previous studies) to trial, the change in higher risk patients evaluated thoroughly (67%→81% vs 78%→73%, P = .01), and potential cases of missed abusive head trauma (40%→21% vs 29%→32%, P = .003), diverged significantly. We did not identify a significant divergence in the number of estimated cases of missed abusive head trauma (15%→7% vs 11%→13%, P = .22).PediBIRN-4 CDR application facilitated changes in abuse evaluations that reduced potential cases of missed abusive head trauma in PICU settings.ClinicalTrials.gov: NCT03162354.

Summary Background Paediatric acute respiratory distress syndrome (PARDS) is associated with high mortality in children, but until recently no paediatric-specific diagnostic criteria existed. The Pediatric Acute Lung Injury Consensus Conference (PALICC) definition was developed to overcome limitations of the Berlin definition, which was designed and validated for adults. We aimed to determine the incidence and outcomes of children who meet the PALICC definition of PARDS. Methods In this international, prospective, cross-sectional, observational study, 145 paediatric intensive care units (PICUs) from 27 countries were recruited, and over a continuous 5 day period across 10 weeks all patients were screened for enrolment. Patients were included if they had a new diagnosis of PARDS that met PALICC criteria during the study week. Exclusion criteria included meeting PARDS criteria more than 24 h before screening, cyanotic heart disease, active perinatal lung disease, and preparation or recovery from a cardiac intervention. Data were collected on the PICU characteristics, patient demographics, and elements of PARDS (ie, PARDS risk factors, hypoxaemia severity metrics, type of ventilation), comorbidities, chest imaging, arterial blood gas measurements, and pulse oximetry. The primary outcome was PICU mortality. Secondary outcomes included 90 day mortality, duration of invasive mechanical and non-invasive ventilation, and cause of death. Findings Between May 9, 2016, and June 16, 2017, during the 10 study weeks, 23 280 patients were admitted to participating PICUs, of whom 744 (3·2%) were identified as having PARDS. 95% (708 of 744) of patients had complete data for analysis, with 17% (121 of 708; 95% CI 14–20) mortality, whereas only 32% (230 of 708) of patients met Berlin criteria with 27% (61 of 230) mortality. Based on hypoxaemia severity at PARDS diagnosis, mortality was similar among those who were non-invasively ventilated and with mild or moderate PARDS (10–15%), but higher for those with severe PARDS (33% [54 of 165; 95% CI 26–41]). 50% (80 of 160) of non-invasively ventilated patients with PARDS were subsequently intubated, with 25% (20 of 80; 95% CI 16–36) mortality. By use of PALICC PARDS definition, severity of PARDS at 6 h after initial diagnosis (area under the curve [AUC] 0·69, 95% CI 0·62–0·76) discriminates PICU mortality better than severity at PARDS diagnosis (AUC 0·64, 0·58–0·71), and outperforms Berlin severity groups at 6 h (0·64, 0·58–0·70; p=0·01). Interpretation The PALICC definition identified more children as having PARDS than the Berlin definition, and PALICC PARDS severity groupings improved the stratification of mortality risk, particularly when applied 6 h after PARDS diagnosis. The PALICC PARDS framework should be considered for use in future epidemiological and therapeutic research among children with PARDS. Funding University of Southern California Clinical Translational Science Institute, Sainte Justine Children's Hospital, University of Montreal, Canada, Reseau en Sante Respiratoire du Fonds de Recherche Quebec-Sante, and Children's Hospital Los Angeles, Department of Anesthesiology and Critical Care Medicine.

Traumatic brain injury (TBI) refers to a spectrum of brain injury that can result in significant morbidity and mortality in pediatric patients. Pediatric head trauma is distinct from adult TBI. The purpose of this review article is to discuss pediatric TBI and current treatment modalities available.

Objective To replicate the previously published finding that the absence of a history of trauma in a child with obvious traumatic head injuries demonstrates high specificity and high positive predictive value (PPV) for abusive head trauma. Study design This was a secondary analysis of a deidentified, cross-sectional dataset containing prospective data on 346 young children with acute head injury hospitalized for intensive care across 18 sites between 2010 and 2013, to estimate the diagnostic relevance of a caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma inconsistent with the child's gross motor skills. Cases were categorized as definite or not definite abusive head trauma based solely on patients' clinical and radiologic findings. For each presumptive historical “red flag,” we calculated sensitivity, specificity, predictive values, and likelihood ratio (LR) with 95% CI for definite abusive head trauma in all patients and also in cohorts with normal, abnormal, or persistent abnormal neurologic status. Results A caregiver's specific denial of any trauma demonstrated a specificity of 0.90 (95% CI, 0.84-0.94), PPV of 0.81 (95% CI, 0.71-0.88), and a positive LR (LR+) of 4.83 (95% CI, 3.07-7.61) for definite abusive head trauma in all patients. Specificity and LR+ were lowest—not highest—in patients with persistent neurologic abnormalities. The 2 other historical red flags showed similar trends. Conclusions A caregiver's specific denial of any trauma, changing history of accidental trauma, or history of accidental trauma that is developmentally inconsistent are each highly specific (>0.90) but may provide weaker support than previously reported for a diagnosis of abusive head trauma in patients with persistent neurologic abnormalities.

OBJECTIVE: To characterize racial and ethnic disparities in the evaluation and reporting of suspected abusive head trauma (AHT) across the 18 participating sites of the Pediatric Brain Injury Research Network (PediBIRN). We hypothesized that such disparities would be confirmed at multiple sites and occur more frequently in patients with a lower risk for AHT. STUDY DESIGN: Aggregate and site-specific analysis of the cross-sectional PediBIRN dataset, comparing AHT evaluation and reporting frequencies in subpopulations of white/non-Hispanic and minority race/ethnicity patients with lower vs higher risk for AHT. RESULTS: In the PediBIRN study sample of 500 young, acutely head-injured patients hospitalized for intensive care, minority race/ethnicity patients (n = 229) were more frequently evaluated (P < .001; aOR, 2.2) and reported (P = .001; aOR, 1.9) for suspected AHT than white/non-Hispanic patients (n = 271). These disparities occurred almost exclusively in lower risk patients, including those ultimately categorized as non-AHT (P = .001 [aOR, 2.4] and P = .003 [aOR, 2.1]) or with an estimated AHT probability of ≤25% (P < .001 [aOR, 4.1] and P < .001 [aOR, 2.8]). Similar site-specific analyses revealed that these results reflected more extreme disparities at only 2 of 18 sites, and were not explained by local confounders. CONCLUSION: Significant race/ethnicity-based disparities in AHT evaluation and reporting were observed at only 2 of 18 sites and occurred almost exclusively in lower risk patients. In the absence of local confounders, these disparities likely represent the impact of local physicians’ implicit bias.

1) To describe clinical characteristics, hospital courses, and outcomes of a cohort of children cared for within the Pediatric Emergency Care Applied Research Network who experienced in-hospital cardiac arrest with sustained return of circulation between July 1, 2003 and December 31, 2004, and 2) to identify factors associated with hospital mortality in this population. These data are required to prepare a randomized trial of therapeutic hypothermia on neurobehavioral outcomes in children after in-hospital cardiac arrest.Retrospective cohort study.Fifteen children's hospitals associated with Pediatric Emergency Care Applied Research Network.Patients between 1 day and 18 years of age who had cardiopulmonary resuscitation and received chest compressions for1 min, and had a return of circulation for20 mins.None.A total of 353 patients met entry criteria; 172 (48.7%) survived to hospital discharge. Among survivors, 132 (76.7%) had good neurologic outcome documented by Pediatric Cerebral Performance Category scores. After adjustment for age, gender, and first documented cardiac arrest rhythm, variables available before and during the arrest that were independently associated with increased mortality included pre-existing hematologic, oncologic, or immunologic disorders, genetic or metabolic disorders, presence of an endotracheal tube before the arrest, and use of sodium bicarbonate during the arrest. Variables associated with decreased mortality included postoperative cardiopulmonary resuscitation. Extending the time frame to include variables available before, during, and within 12 hours following arrest, variables independently associated with increased mortality included the use of calcium during the arrest. Variables associated with decreased mortality included higher minimum blood pH and pupillary responsiveness.Many factors are associated with hospital mortality among children after in-hospital cardiac arrest and return of circulation. Such factors must be considered when designing a trial of therapeutic hypothermia after cardiac arrest in pediatric patients.

To aggregate data across institutions to identify, characterize, and differentiate potential survivors from nonsurvivors based on etiology of event.To evaluate the association of the cardiopulmonary resuscitation (CPR) duration and probability of survival (Ps), stratified by etiology of arrest.In-hospital cardiac arrests occur in 2-6% of pediatric patients with poor survival rates resulting in significant expenditures of time and resources.Retrospective data from six pediatric hospitals on patients suffering from pulseless cardiac arrests receiving CPR for over one minute were analyzed. Data included demographics, reason for code, precardiac arrest diagnosis, devices and treatment, management strategies during cardiac arrest, compression duration, outcome at hospital discharge, and neurologic outcome of survivors at hospital discharge. Results of logistic regression analysis generated predicated probabilities of survival for duration of compression. Patients were stratified by cardiac-induced cardiac arrests (CICA) and respiratory-induced cardiac arrest (RICA).A total of 257 patients were included, and 27% of CICA and 35% of RICA patients survived to hospital discharge. Ps was initially lower for the CICA patients (Ps at 1 min = 29%) and remained constant (Ps at 60 min = 25%). RICA patients'Ps was higher initially (Ps at 1 min = 62%) but demonstrated a dramatic drop within the first 60 min of CPR (Ps at 60 min = 0.2%).Probability of survival curves based on duration of CPR was statistically significantly different for CICA patients compared to RICA patients.

Objectives: To describe a large cohort of children with out-of- hospital cardiac arrest with return of circulation and to identify factors in the early postarrest period associated with survival. These objectives were for planning an interventional trial of therapeutic hypothermia after pediatric cardiac arrest. Methods: A retrospective cohort study was conducted at 15 Pediatric Emergency Care Applied Research Network clinical sites over an 18-month study period. All children from 1 day (24 hrs) to 18 yrs of age with out-of-hospital cardiac arrest and a history of at least 1 min of chest compressions with return of circulation for at least 20 mins were eligible. Measurements and Main Results: One hundred thirty-eight cases met study entry criteria; the overall mortality was 62% (85 of 138 cases). The event characteristics associated with increased survival were as follows: weekend arrests, cardiopulmonary resus- citation not ongoing at hospital arrival, arrest rhythm not asystole, no atropine or NaHCO3, fewer epinephrine doses, shorter duration of cardiopulmonary resuscitation, and drowning or asphyxial arrest event. For the 0- to 12-hr postarrest return-of-circulation period, absence of any vasopressor or inotropic agent (dopamine, epineph- rine) use, higher lowest temperature recorded, greater lowest pH, lower lactate, lower maximum glucose, and normal pupillary re- sponses were all associated with survival. A multivariate logistic model of variables available at the time of arrest, which controlled for gender, age, race, and asystole or ventricular fibrillation/ventricular tachycardia anytime during the arrest, found the administration of atropine and epinephrine to be associated with mortality. A second model using additional information available up to 12 hrs after return of circulation found 1) preexisting lung or airway disease; 2) an etiology of arrest drowning or asphyxia; 3) higher pH, and 4) bilateral reactive pupils to be associated with lower mortality. Receiving more than three doses of epinephrine was associated with poor outcome in 96% (44 of 46) of cases. Conclusions: Multiple factors were identified as associated with survival after out-of-hospital pediatric cardiac arrest with the return of circulation. Additional information available within a few hours after the return of circulation may diminish outcome associations of factors available at earlier times in regression models. These factors should be considered in the design of future interventional trials aimed to improve outcome after pedi- atric cardiac arrest. (Crit Care Med 2011; 39:141-149)

OBJECTIVE: Our purpose was to examine alterations in end-of-life support in a multiinstitutional sample of PICUs. METHODS: This was a retrospective, descriptive study. Variables collected included end-of-life support category, race, length of stay, operative status, reason for admission, and Pediatric Index of Mortality 2 score, as well as the number of ICU beds and the presence of trainees. RESULTS: There were 1745 deaths at 35 institutions between January 1, 2004, and September 30, 2005. Of those, 1263 had complete data and were analyzed. The end-of-life support category distribution was as follows: brain death, 296 (23%); do not resuscitate, 205 (16%); limitation of support, 36 (3%); withdrawal of support, 579 (46%); no limitation, 124 (10%); no advance directives, 23 (2%). For further analyses, end-of-life support categories were grouped as limitation (ie, do not resuscitate, limitation of support, or withdrawal of support) versus no limitation (ie, no limitation or no advance directive). Brain death was not included in further analyses. The majority of deaths were in the limitation group (n = 820 [85%]), and 12 (40%) of 30 institutions had 100% of deaths in this group. There were significant differences between institutions (P < .001). Decisions for limitation were seen less frequently in the black race (112 [76%] of 147 deaths; P = .037) and in institutions with no trainees (56 [69%] of 81 deaths; P < .001). CONCLUSIONS: Decisions to limit support are common. Black race and an absence of trainees are associated with decreased frequency of limitation decisions.

To describe a large multicenter cohort of pediatric cardiac arrest (CA) with return of circulation (ROC) from either the in-hospital (IH) or the out-of-hospital (OH) setting and to determine whether significant differences related to pre-event, arrest event, early postarrest event characteristics, and outcomes exist that would be critical in planning a clinical trial of therapeutic hypothermia (TH).: Retrospective cohort study.: Fifteen Pediatric Emergency Care Applied Research Network sites.: Patients aged 24 hours to 18 years with either IH or OH CA who had a history of at least 1 minute of chest compressions and ROC for at least 20 minutes were eligible.: None.: A total of 491 patients met study entry criteria with 353 IH cases and 138 OH cases. Major differences between the IH and OH cohorts were observed for patient prearrest characteristics, arrest event initial rhythm described, and arrest medication use. Several postarrest interventions were used differently, however, the use of TH was similar (5%) in both cohorts. During the 0-12-hour interval following ROC, OH cases had lower minimum temperature and pH, and higher maximum serum glucose recorded. Mortality was greater in the OH cohort (62% vs. 51%, p = 0.04) with the cause attributed to a neurologic indication much more frequent in the OH than in the IH cohort (69% vs. 20%; p0.01).: For pediatric CA with ROC, several major differences exist between IH and OH cohorts. The finding that the etiology of death was attributed to neurologic indications much more frequently in OH arrests has important implications for future research. Investigators planning to evaluate the efficacy of new interventions, such as TH, should be aware that the IH and OH populations differ greatly and require independent clinical trials.

We report the survival of a 15-year-old girl in whom clinical rabies developed one month after she was bitten by a bat. Treatment included induction of coma while a native immune response matured; rabies vaccine was not administered. The patient was treated with ketamine, midazolam, ribavirin, and amantadine. Probable drug-related toxic effects included hemolysis, pancreatitis, acidosis, and hepatotoxicity. Lumbar puncture after eight days showed an increased level of rabies antibody, and sedation was tapered. Paresis and sensory denervation then resolved. The patient was removed from isolation after 31 days and discharged to her home after 76 days. At nearly five months after her initial hospitalization, she was alert and communicative, but with choreoathetosis, dysarthria, and an unsteady gait.

Traumatic brain injury (TBI) is a leading cause of death and disability in the United States. To implement more effective injury prevention and treatment programs, it is important to identify the regional impact, causes, risk factors, and trends of TBI. This report summarizes the public health impact of TBI in Wisconsin.Data on fatal and non-fatal TBI injuries in Wisconsin in 2001 were obtained from 2 separate data sources: National Center for Vital Statistics and the Wisconsin Bureau for Health Information. Rates of fatal and nonfatal TBI were calculated using 2000 population estimates as denominators.There were 1059 TBI fatalities and 4006 living TBI-related hospital discharges in Wisconsin in 2001. The overall rate of TBI in Wisconsin for 2001 was 94.4 per 100,000 people. The number of fatal and nonfatal TBI related injuries was higher for males than females, at all ages, except nonfatal injuries in persons older than 65 years. Fatalities from TBI were highest in young adults and the elderly.TBI is a major cause of death and hospitalizations in Wisconsin. Male teens and young adults, and the elderly are high-risk groups for TBI. Preventive measures should be aimed at these high-risk groups.