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The Sainte-Justine Head Trauma Pathway helps physicians' decision-making in the evaluation of head trauma in young children. We evaluated the pathway to identify clinically important traumatic brain injury (ciTBI) among children younger than two years who presented to a pediatric emergency department for a head trauma. The primary outcome was ciTBI, defined as a TBI complicated by death, neurosurgery, intubation or hospitalization for more than one night. Among 2258 children, we reviewed the charts of all hospitalized children (n = 100) and a random sample of nonhospitalized children (n = 101) and found a ciTBI in 26 patients. The Sainte-Justine Head Trauma Pathway and the Pediatric Emergency Care Applied Research Network Pediatric Head Injury Prediction Rule both had a sensitivity of 96% (95% confidence interval 81%-100%). We found that the Sainte-Justine Head Trauma Pathway does not improve the identification of ciTBI among young children with head trauma., Head trauma is a common chief complaint among children visiting the emergency department (ED). The Pediatric Emergency Care Applied Research Network (PECARN) Head Injury Prediction Rule is the decision tool [...]

OBJECTIVE. Despite recognition that dying children and their families have unique palliative care needs, there has been little empirical inquiry of parent perspectives to improve the quality of end-of-life care and communication. The purpose of this study was to identify and describe the priorities and recommendations for end-of-life care and communication from the parents' perspective. METHODS. This was a qualitative study based on parental responses to open-ended questions on anonymous, self-administered questionnaires, conducted at 3 pediatric ICUs in Boston, Massachusetts. Fifty-six parents whose children had died in PICUs after withdrawal of life support participated in this study. We measured parent-identified priorities for end-of-life care and communication. RESULTS. Parents identified 6 priorities for pediatric end-of-life care including honest and complete information, ready access to staff, communication and care coordination, emotional expression and support by staff, preservation of the integrity of the parent-child relationship, and faith. CONCLUSIONS. Parental priorities and recommendations offer simple yet compelling guidance to improve pediatric end-of-life clinical practice and research. Key Words end-of-life care, pediatric intensive care, communication, family-centered care, pediatric palliative care, THE DEATH OF a child is an unexpected and unimagined event for most families. Even families of children who are born with life-shortening conditions cannot truly be prepared, because the [...]

A nutritional screen for patients in pediatric intensive care appears to accurately identify those who are at risk of poor outcomes. Researchers evaluated the nutritional status of 25 children with respiratory syncytial virus infection in intensive care by examining their medical condition, their growth, their laboratory results, and their dietary intake. The results of this screen were significantly associated with the patients' outcomes, as measured by the days the children spent in the hospital, on mechanical ventilation, given oxygen, or not given food enterally. Eleven of the children were considered low risk, and the other 14 were considered high risk. Each of the outcome indicators showed significant differences between the low risk and high risk groups. The nutritional screen may have general usefulness in determining which pediatric patients require special intervention., Objective. We sought to validate a nutritional screen that was easy to perform and accurate in identifying pediatric patients at risk for adverse clinical outcomes based on their nutritional status. Methods. Twenty-five consecutive patients admitted to our pediatric intensive care complex between July 1992 and July 1993 with a primary diagnosis of respiratory syncytial virus infection were evaluated. Nutritional screen parameters included historical (disease and condition), growth (anthropometrics), and laboratory (hemoglobin, lymphocyte count, and albumin) data. Outcome measures included days in the hospital, days of mechanical ventilation, days not fed enterally, and days receiving oxygen. Results. Regression analysis indicated that a score of 5 or less signified a low risk of adverse outcome and a score of greater than 5 signified a high risk. Eleven of 25 patients had low scores, and 14 of 25 had high scores. All outcome measures differed significantly between the low- and high-risk groups: median number of days in the hospital, 7 and 13.5, respectively, median number of days of ventilation, 0 and 8.5, respectively; median number of days without enteral feeding, 3 and 8.5, respectively; and median number of days receiving oxygen, 4 and 20, respectively. Conclusions. Our nutritional screen identifies patients in the pediatric intensive care complex with respiratory syncytial virus at increased risk for adverse outcome. This screen may be useful in identifying pediatric patients at risk for adverse clinical outcomes from other medical diagnoses. Pediatrics 1996;97:543-546; respiratory syncytial virus, nutritional screen, pediatrics, intensive care., Hospitalized patients with nutritional deficits are at risk for increased morbidity and mortality. Early identification of these patients would allow timely intervention, potentially decreasing the length of hospital stays, cost [...]

Doctors must participate in the decision to forgo life-sustaining medical treatment (LSMT) for critically ill children. LSMT consists of all treatments that may prolong the life of patients. Patients or their legal decision-makers have the right to be informed about diagnostic and treatment options and to refuse all or any part of treatment. Doctors are obligated to provide all relevant information, treatment risks and benefits and advice regarding the best option in their professional opinion. If doctors are unable or unwilling to act on patients' or decision-makers' wishes, they must arrange for care by another doctor before ending the relationship. In the case of children lacking the decision-making capacity, surrogates must make health care decisions for patients based on their best interests, inferences about their preferences and any expressed wishes. Doctors should document all decisions in the patient's medical record.

The 1970s and 1980s have seen a dramatic maturation of pediatric critical care medicine. THe explosion of knowledge regarding the pathophysiology of life-threatening processes and the technologic means of monitoring and treating pediatric victims have prompted enormous growth in the field. A related development has been the advent of the pediatric intensive care unit (PICU). Now that pediatric critical care is recognized as a new subspecialty and pediatric critical care medicine training programs have been accredited, there is a call for the revision of existing guidelines for the pediatric intensive care unit. Minimum guidelines for level I and II PICUs are set forth that include organization and administrative structure, physical design and facilities, personnel, hospital facilities and services, drugs and equipment, prehospital care, quality assessment and training and continuing education.

Objective. - To determine the time from triage in an emergency department until administration of parenteral antibiotics in children with bacterial meningitis. Research Design. - Retrospective review of medical records and survey of medical subspecialists in infectious diseases and emergency medicine. Setting. - Emergency departments of two university-affiliated pediatric hospitals. Participants. - All children with bacterial meningitis identified in medical records from 1987 to 1989 (N=93). Measurements. - For each child, the time from presentation to the emergency department until administration of antibiotics (AB time) was determined; when possible, time from triage to contact with a physician, from triage to lumbar puncture, and from lumbar puncture to administration of antibiotics was measured. We then surveyed specialists in both pediatric infectious diseases (n=23) and pediatric emergency medicine (n=54) as to their beliefs about AB time in children with meningitis. Statistical/Analyses. - Mann-Whitney Rank Sum Test and Kruskal-Wallis Test. Results. - Median AB time was 2.0 hours (interquartile range, 1.25 to 3.33 hours). Only one (1%) of 93 children received antibiotics within 30 minutes of presentation. Median time from triage until contact with a physician was 0.45 hour. Median time from lumbar puncture until antibiotics administration was about 0.5 hour. The estimates of median AB time differed significantly between emergency medicine (0.93 hour) and infectious disease (1.45 hours) experts, and estimates from the differed significantly from the median AB time (2.0 hours) actually observed. Conclusions. - These data reveal hat the usual and customary practice (ie, standard medical care) by qualified physicians may differ from opinions of standard medical care promulgated by medical experts. Even among experts there is a wide range of (mistaken) opinions about standard medical care. Insofar as jurors in medical malpractice cases are instructed to consider what physicians 'ordinarily do in similar circumstances,' a data-based definition of 'standard' medical care should supplant anecdotal testimony by individual expert witnesses. (AJDC. 1993;147:40-44)