High-flow nasal cannula implementation has not reduced intubation rates for bronchiolitis in Canada

Background and Objective: Bronchiolitis is the most common reason for admission to hospital in the first year of life, with increasing hospitalization rates in Canada. Respiratory support with high-flow nasal cannula (HFNC) is being routinely used in paediatric centres, though the evidence of efficacy is continuing to be evaluated. We examined the impact of HFNC on intubation rates, hospital and paediatric critical care unit (PCCU) length of stay (LOS), and PCCU admission rates in paediatric tertiary centres in Canada. Methods: We conducted a multicentre, interrupted time series analysis to examine intubation rates pre- to postimplementation of HFNC for bronchiolitis. Data were obtained from the Canadian Institute for Health Information database. Paediatric tertiary centres that introduced HFNC between 2009 and 2014 were included, and data were collected from April 2005 to March 2017. Results: A total of 17,643 patients met inclusion criteria. There was no significant change in intubation rates after the introduction of HFNC. There was a significant increase in PCCU admission, with a decrease in the PCCU LOS following the introduction of HFNC. There was no significant change in average hospital LOS after HFNC was introduced. Conclusions: This study adds to the evolving evidence showing that overall disease course is not modified by the use of HFNC. The initiation of HFNC in Canadian paediatric centres resulted in no significant change in intubation rates or average LOS in hospital, but had an increase in PCCU admissions. Careful monitoring of new technologies on their clinical impact as well as health care resource utilization is warranted

Refractory Hypotension Caused by Prazosin Overdose Combined With Acetaminophen and Naproxen Toxicity: A Case Report and Review of the Literature.

Background Pediatric exposure to prazosin is unusual because it is most commonly indicated for the treatment of hypertension. Prazosin\u27s increase in popularity as a treatment for posttraumatic stress disorder makes it important for emergency physicians to be aware of how to manage potential toxic ingestion because of prazosin overdose. Case Report A 16-year-old, 76-kg female presented after ingesting 110 mg of prazosin, 209.3 g of acetaminophen, and 55 g of naproxen. She was admitted to the pediatric intensive care unit for rapidly deteriorating hypotension (lowest blood pressure 47/19 mm Hg) refractory to aggressive fluid resuscitation and infusions of epinephrine and norepinephrine each at 0.5 mcg/kg/min. Stabilization of blood pressure was eventually achieved, and associated with use of a vasopressin infusion of 0.004 units/kg/min. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because of the increasing exposure of children to prazosin, clinicians should be aware of the pharmacology behind alpha-1 antagonist overdose and consider treatment options, such as vasopressin, when hypotension is resistant to standard fluid and catecholamine therapy

Pediatric Forefoot Fractures: Assessment of Fracture Patterns and Predictors of Complicated Outcome.

BACKGROUND: Forefoot fractures account for 6% to 10% of fractures in children, and although the majority heals with supportive treatment, complications may lead to pain and disability. No previous study in children has evaluated complication risk in the emergency department based on initial assessment characteristics. STUDY OBJECTIVES: The study aim was to identify the radiological and clinical variables that increase the complication rate of pediatric forefoot fractures. This may help emergency physicians refer patients who require more thorough follow-up or surgical intervention. METHODS: We evaluated 497 forefoot fractures on initial presentation to a pediatric emergency department at the Children\u27s Hospital at London Health Science Centre over a 6-year period. We collected variables such as degree of angulation, displacement, number of concurrent fractures, and demographic data such as age and sex. We then determined the variables associated with complications by reviewing each patient\u27s chart. RESULTS: Overall, there was a 6.4% complication rate. Analysis identified sex as an important predictor of complications. Females, although representing approximately one third of the sample, represented nearly two thirds of the cases with complicated outcomes (P = 0.001; odds ratio [OR], 4.67). Increased number of fractures was also significant (P = 0.01; OR, 2.41) as was increasing age (P = 0.01; OR, 1.17) and patients who chose to return to the emergency department (P \u3c 0.05; OR, 5.282). Lateral angulation/displacement and anteroposterior angulation/displacement were not associated with increased complications. CONCLUSION: Identifying features, such as female sex, increasing age, multiple fractures, and return to emergency departments for repeat visits, may help guide the emergency physician on whom to refer for specialized care