Manish I. Shah, MD, MS

All Publications

• Public support for and concerns regarding pediatric dose optimization for seizures in emergency medical services: An exception from informed consent (EFIC) trial ACADEMIC EMERGENCY MEDICINE Ward, C. E., Adelgais, K. M., Holsti, M., Jacobsen, K. K., Simon, H. K., Morris, C. R., Gonzalez, V. M., Lerner, G., Ghaffari, K., VanBuren, J. M., Lerner, E., Shah, M. I., Pediat Emergency Care Appl Res 2024

  Abstract

  Federal regulations allow exception from informed consent (EFIC) to study emergent conditions when obtaining prospective consent is not feasible. Little is known about public views on including children in EFIC studies. The Pediatric Dose Optimization for Seizures in EMS (PediDOSE) trial implements age-based, standardized midazolam dosing for pediatric seizures. The primary objective of this study was to determine public support for and concerns about the PediDOSE EFIC trial. The secondary objective was to assess how support for PediDOSE varied by demographics.We conducted a mixed-methods study in 20 U.S. communities. Participants reviewed information about PediDOSE before completing an online survey. Descriptive data were generated. Univariable and multivariable logistic regression analysis identified factors associated with support for PediDOSE. Reviewers identified themes from free-text response data regarding participant concerns.Of 2450 respondents, 79% were parents/guardians, and 20% had a child with previous seizures. A total of 96% of respondents supported PediDOSE being conducted, and 70% approved of children being enrolled without prior consent. Non-Hispanic Black respondents were less likely than non-Hispanic White respondents to support PediDOSE with an adjusted odds ratio (aOR) of 0.57 (95% CI 0.42-0.75). Health care providers were more likely to support PediDOSE, with strongest support among prehospital emergency medicine clinicians (aOR 5.82, 95% CI 3.19-10.62). Age, gender, parental status, and level of education were not associated with support of PediDOSE. Common concerns about PediDOSE included adverse effects, legal and ethical concerns about enrolling without consent, and potential racial bias.In communities where this study will occur, most respondents supported PediDOSE being conducted with EFIC and most approved of children being enrolled without prior consent. Support was lowest among non-Hispanic Black respondents and highest among health care providers. Further research is needed to determine optimal ways to address the concerns of specific racial and ethnic groups when conducting EFIC trials.

  View details for DOI 10.1111/acem.14884

  View details for Web of Science ID 001180760100001

  View details for PubMedID 38450918

• Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI-AS-ODT). Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Fishe, J. N., Garvan, G., Bertrand, A., Burcham, S., Hendry, P., Shah, M., Kothari, K., Ashby, D. W., Ostermeyer, D., Riney, L., Semenova, O., Abo, B., Abes, B., Shimko, N., Myers, E., Frank, M., Turner, T., Kemp, M., Landry, K., Roland, G., Blake, K. V. 2024; 31 (1): 49-60

  Abstract

  In the emergency department (ED), prompt administration of systemic corticosteroids for pediatric asthma exacerbations decreases hospital admission rates. However, there is sparse evidence for whether earlier administration of systemic corticosteroids by emergency medical services (EMS) clinicians, prior to ED arrival, further improves pediatric asthma outcomes.Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial is a multicenter, observational, nonrandomized stepped-wedge design study with seven participating EMS agencies who adopted an oral systemic corticosteroid (OCS) into their protocols for pediatric asthma treatment. Using univariate analyses and multivariable mixed-effects models, we compared hospital admission rates for pediatric asthma patients ages 2-18 years before and after the introduction of a prehospital OCS and for those who did and did not receive a systemic corticosteroid from EMS.A total of 834 patients were included, 21% of whom received a systemic corticosteroid from EMS. EMS administration of systemic corticosteroids increased after the introduction of an OCS from 14.7% to 28.1% (p < 0.001). However, there was no significant difference between hospital admission rates and ED length of stay before and after the introduction of OCS or between patients who did and did not receive a systemic corticosteroid from EMS. Mixed-effects models revealed that age 14-18 years (coefficient -0.83, p = 0.002), EMS administration of magnesium (coefficient 1.22, p = 0.04), and initial EMS respiratory severity score (coefficient 0.40, p < 0.001) were significantly associated with hospital admission.In this multicenter study, the addition of an OCS into EMS agency protocols for pediatric asthma exacerbations significantly increased systemic corticosteroid administration but did not significantly decrease hospital admission rates. As overall EMS systemic corticosteroid administration rates were low, further work is required to understand optimal implementation of EMS protocol changes to better assess potential benefits to patients.

  View details for DOI 10.1111/acem.14813

  View details for PubMedID 37786991

  View details for PubMedCentralID PMC10842452

• Examination of disparities in prehospital encounters for pediatric asthma exacerbations. Journal of the American College of Emergency Physicians open Riney, L., Palmer, S., Finlay, E., Bertrand, A., Burcham, S., Hendry, P., Shah, M., Kothari, K., Ashby, D. W., Ostermayer, D., Semenova, O., Abo, B. N., Abes, B., Shimko, N., Myers, E., Frank, M., Turner, T., Kemp, M., Landry, K., Roland, G., Fishe, J. N. 2023; 4 (5): e13042

  Abstract

  There are disparities in multiple aspects of pediatric asthma care; however, prehospital care disparities are largely undescribed. This study's objective was to examine racial and geographic disparities in emergency medical services (EMS) medication administration to pediatric patients with asthma.This is a substudy of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial, which includes data from pediatric asthma patients ages 2-18 years. We examined rates of EMS administration of systemic corticosteroids and inhaled bronchodilators by patient race. We geocoded EMS scene addresses, characterized the locations' neighborhood-based conditions and resources relevant to children using the Child Opportunity Index (COI) 2.0, and analyzed associations between EMS scene address COI with medications administered by EMS.A total of 765 patients had available racial data and 825 had scene addresses that were geocoded to a COI. EMS administered at least 1 bronchodilator to 84.7% (n = 492) of non-White patients and 83.2% of White patients (n = 153), P = 0.6. EMS administered a systemic corticosteroid to 19.4% (n = 113) of non-White patients and 20.1% (n = 37) of White patients, P = 0.8. There was a significant difference in bronchodilator administration between COI categories of low/very low versus moderate/high/very high (85.0%, n = 485 vs. 75.9%, n = 192, respectively, P = 0.003).There were no racial differences in EMS administration of medications to pediatric asthma patients. However, there were significantly higher rates of EMS bronchodilator administration for encounters in low/very low COIs. That latter finding may reflect inequities in asthma exacerbation severity for patients living in disadvantaged areas.

  View details for DOI 10.1002/emp2.13042

  View details for PubMedID 37811360

  View details for PubMedCentralID PMC10560007

• National Variation in EMS Response and Antiepileptic Medication Administration for Children with Seizures in the Prehospital Setting. The western journal of emergency medicine Firnberg, M. T., Lerner, E. B., Nan, N., Ma, C. X., Shah, M. I., Mann, N. C., Dayan, P. S. 2023; 24 (4): 805-813

  Abstract

  Prehospital Advanced Life Support (ALS) is important to improve patient outcomes in children with seizures, yet data is limited regarding national prehospital variation in ALS response for these children. We aimed to determine the variation in ALS response and prehospital administration of antiepileptic medication for children with seizures across the United States.We analyzed children <19 years with 9-1-1 dispatch codes for seizure in the 2019 National Emergency Medical Services Information System dataset. We defined ALS response as ALS-paramedic, ALS-Advanced Emergency Medical Technician, or ALS-intermediate responses. We conducted regression analyses to identify associations between ALS response (primary outcome), antiepileptic administration (secondary outcome) and age, gender, location, and US census regions.Of 147,821 pediatric calls for seizures, 88% received ALS responses. Receipt of ALS response was associated with urbanicity, with wilderness (adjusted odds ratio [aOR] 0.44, 0.39-0.49) and rural (aOR 0.80, 0.75-0.84) locations less likely to have ALS responses than urban areas. Of 129,733 emergency medical service (EMS) activations with an ALS responder's impression of seizure, antiepileptic medications were administered in 9%. Medication administration was independently associated with age (aOR 1.008, 95% confidence interval [CI] 1.005-1.010) and gender (aOR 1.22, 95% CI 1.18-1.27), with females receiving medications more than males. Of the 11,698 children who received antiepileptic medications, midazolam was the most commonly used (83%).The majority of children in the US receive ALS responses for seizures. Although medications are infrequently administered, the majority who received medications had midazolam given, which is the current standard of care. Further research should determine the proportion of children who are continuing to seize upon EMS arrival and would most benefit from immediate treatment.

  View details for DOI 10.5811/westjem.59396

  View details for PubMedID 37527390

  View details for PubMedCentralID PMC10393459

• EMS Administration of Systemic Corticosteroids to Pediatric Asthma Patients: An Analysis by Severity and Transport Interval PREHOSPITAL EMERGENCY CARE Riney, L., Palmer, S., Finlay, E., Bertrand, A., Burcham, S., Hendry, P., Shah, M., Kothari, K., Ashby, D., Ostermayer, D., Semenova, O., Abo, B. N., Abes, B., Shimko, N., Myers, E., Frank, M., Turner, T., Kemp, M., Landry, K., Roland, G., Fishe, J. 2023; 27 (7): 900-907

  Abstract

  Pediatric asthma exacerbations are a common cause of emergency medical services (EMS) encounters. Bronchodilators and systemic corticosteroids are mainstays of asthma exacerbation therapy, yet data on the efficacy of EMS administration of systemic corticosteroids are mixed. This study's objective was to assess the association between EMS administration of systemic corticosteroids to pediatric asthma patients on hospital admission rates based on asthma exacerbation severity and EMS transport intervals.This is a sub-analysis of the Early Administration of Steroids in the Ambulance Setting: An Observational Design Trial (EASI AS ODT). EASI AS ODT is a non-randomized, stepped wedge, observational study examining outcomes one year before and one year after seven EMS agencies incorporated an oral systemic corticosteroid option into their protocols for the treatment of pediatric asthma exacerbations. We included EMS encounters for patients ages 2-18 years confirmed by manual chart review to have asthma exacerbations. We compared hospital admission rates across asthma exacerbation severities and EMS transport intervals using univariate analyses. We geocoded patients and created maps to visualize the general trends of patient characteristics.A total of 841 pediatric asthma patients met inclusion criteria. While most patients were administered inhaled bronchodilators by EMS (82.3%), only 21% received systemic corticosteroids, and only 19% received both inhaled bronchodilators and systemic corticosteroids. Overall, there was no significant difference in hospitalization rates between patients who did and did not receive systemic corticosteroids from EMS (33% vs. 32%, p = 0.78). However, although not statistically significant, for patients who received systemic corticosteroids from EMS, there was an 11% decrease in hospitalizations for mild exacerbation patients and a 16% decrease in hospitalizations for patients with EMS transport intervals greater than 40 min.In this study, systemic corticosteroids were not associated with a decrease in hospitalizations of pediatric patients with asthma overall. However, while limited by small sample size and lack of statistical significance, our results suggest there may be a benefit in certain subgroups, particularly patients with mild exacerbations and those with transport intervals longer than 40 min. Given the heterogeneity of EMS agencies, EMS agencies should consider local operational and pediatric patient characteristics when developing standard operating protocols for pediatric asthma.

  View details for DOI 10.1080/10903127.2023.2234996

  View details for Web of Science ID 001039504800001

  View details for PubMedID 37428954

  View details for PubMedCentralID PMC10592383

• Evidence-Based Guidelines for Prehospital Pain Management: Literature and Methods. Prehospital emergency care Powell, J. R., Browne, L. R., Guild, K., Shah, M. I., Crowe, R. P., Lindbeck, G., Braithwaite, S., Lang, E. S., Panchal, A. R. 2023; 27 (2): 154-161

  Abstract

  Emergency Medical Services (EMS) clinicians commonly encounter patients with acute pain. A new set of evidence-based guidelines (EBG) was developed to assist in the prehospital management of pain. Our objective was to describe the methods used to develop these evidence-based guidelines for prehospital pain management.The EBG development process was supported by a previous systematic review conducted by the Agency for Healthcare Research and Quality (AHRQ) covering nine different population, intervention, comparison, and outcome (PICO) questions. A technical expert panel (TEP) was formed and added an additional pediatric-specific PICO question. Identified evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework and tabulated into Summary of Findings tables. The TEP then utilized a rigorous systematic method, including the PanelVoice function, for recommendation development which was applied to generate Evidence to Decision Tables (EtD). This process involved review of the Summary of Findings tables, asynchronous member judging, and facilitated panel discussion to generate final consensus-based recommendations.The work product described above was completed by the TEP panel from September 2020 to April 2021. For these recommendations, the overall certainty of evidence was very low or low, data for decisions on cost effectiveness and equity were lacking, and feasibility was rated well across all categories. Based on the evidence, one strong and seven conditional recommendations were made, with two PICO questions lacking sufficient evidence to generate a recommendation.We describe a protocol that leveraged established EBG development techniques, the GRADE framework in conjunction with a previous AHRQ systematic review to develop treatment recommendations for prehospital pain management. This process allowed for mitigation of many confounders due to the use of virtual and electronic communication. Our approach may inform future guideline development and increase transparency in the prehospital recommendations development processes.

  View details for DOI 10.1080/10903127.2021.2018074

  View details for PubMedID 34928783

• Impact of Race and Ethnicity on Emergency Medical Services Administration of Opioid Pain Medications for Injured Children. The Journal of emergency medicine Nishijima, D. K., Tancredi, D. J., Adelgais, K. M., Chadha, K., Chang, T. P., Harris, M. I., Leonard, J. C., Lerner, E. B., Linakis, S. W., Lowe, G. S., Magill, C. F., Schwartz, H. P., Shah, M. I., Browne, L. R. 2023; 64 (1): 55-61

  Abstract

  Treatment with analgesics for injured children is often not provided or delayed during prehospital transport.Our aim was to evaluate racial and ethnic disparities with the use of opioids during transport of injured children.We conducted a prospective study of injured children transported to 1 of 10 emergency departments from July 2019 to April 2020. Emergency medical services (EMS) providers were surveyed about prehospital pain interventions during transport. Our primary outcome was the use of opioids. We performed multivariate regression analyses to evaluate the association of patient demographic characteristics (race, ethnicity, age, and gender), presence of a fracture, EMS provider type (Advanced Life Support [ALS] or non-ALS) and experience (years), and study site with the use of opioids.We enrolled 465 patients; 19% received opioids during transport. The adjusted odds ratios (AORs) for Black race and Hispanic ethnicity were 0.5 (95% CI 0.2-1.2) and 0.4 (95% CI 0.2-1.3), respectively. The presence of a fracture (AOR 17.0), ALS provider (AOR 5.6), older patient age (AOR 1.1 for each year), EMS provider experience (AOR 1.1 for each year), and site were associated with receiving opioids.There were no statistically significant associations between race or ethnicity and use of opioids for injured children. The presence of a fracture, ALS provider, older patient age, EMS provider experience, and site were associated with receiving opioids.

  View details for DOI 10.1016/j.jemermed.2022.10.011

  View details for PubMedID 36641254

• Epidemiology of out-of-hospital pediatric airway management in the 2019 national emergency medical services information system data set. Resuscitation Hanlin, E. R., Chan, H. K., Hansen, M., Wendelberger, B., Shah, M. I., Bosson, N., Gausche-Hill, M., VanBuren, J. M., Wang, H. E. 2022; 173: 124-133

  Abstract

  Airway management is an important priority in the care of critically ill children. We sought to provide updated estimates of the epidemiology of pediatric out-of-hospital airway management and ventilation interventions in the United States.We used data from the 2019 National Emergency Medical Services Information System (NEMSIS) data set. We performed a descriptive analysis of all patients < 18 years receiving one or more of the following: bag-valve-mask ventilation (BVM), tracheal intubation (TI), supraglottic airway (SGA) insertion, continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP) and surgical airway placement. We determined success and complication rates for each airway procedure.Among 1,148,943 pediatric patient care encounters, airway and ventilation interventions occurred in 22,637 (1,970 per 100,000 pediatric Emergency Medical Services (EMS) activations), including 64% <11 years old, 56.1% male, 16.9% cardiac arrest, 16.6% injured, and 83.9% in urban areas. Airway interventions included: BVM 3,997 (17.7% of pediatric airway encounters), TI 3,165 (14.0%), SGA 582 (2.6%), CPAP/BiPAP 331 (1.5%) and surgical airway 29 (0.1%). TI success was 75.2% (95% CI 73.7-76.7%) and lowest for the 0-1 month age group (56.8%; 49.2-64.2%). SGA success was 88.0% (95% CI 85.1-90.6%). Vomiting was the most common airway complication (n = 223, 1%).BVM and advanced airway management occur in 1 of every 51 pediatric EMS encounters. BVM is the most commonly prehospital pediatric airway management technique, followed by TI and SGA insertion. These data provide contemporary perspectives of pediatric prehospital airway management.

  View details for DOI 10.1016/j.resuscitation.2022.01.008

  View details for PubMedID 35063620

• Evidence-Based Guidelines for Prehospital Pain Management: Recommendations PREHOSPITAL EMERGENCY CARE Lindbeck, G., Shah, M., Braithwaite, S., Powell, J. R., Panchal, A. R., Browne, L. R., Lang, E. S., Burton, B., Coughenour, J., Crowe, R. P., Degn, H., Hedges, M., Gasper, J., Guild, K., Mattera, C., Nasca, S., Taillac, P., Warth, M. 2023; 27 (2): 144-153

  Abstract

  This project sought to develop evidence-based guidelines for the administration of analgesics for moderate to severe pain by Emergency Medical Services (EMS) clinicians based on a separate, previously published, systematic review of the comparative effectiveness of analgesics in the prehospital setting prepared by the University of Connecticut Evidence-Based Practice Center for the Agency for Healthcare Research and Quality (AHRQ). A technical expert panel (TEP) was assembled consisting of subject matter experts in prehospital and emergency care, and the development of evidence-based guidelines and patient care guidelines. A series of nine "patient/population-intervention-comparison-outcome" (PICO) questions were developed based on the Key Questions identified in the AHRQ systematic review, and an additional PICO question was developed to specifically address analgesia in pediatric patients. The panel made a strong recommendation for the use of intranasal fentanyl over intravenous (IV) opioids for pediatric patients without intravenous access given the supporting evidence, its effectiveness, ease of administration, and acceptance by patients and providers. The panel made a conditional recommendation for the use of IV non-steroidal anti-inflammatory drugs (NSAIDs) over IV acetaminophen (APAP). The panel made conditional recommendations for the use of either IV ketamine or IV opioids; for either IV NSAIDs or IV opioids; for either IV fentanyl or IV morphine; and for either IV ketamine or IV NSAIDs. A conditional recommendation was made for IV APAP over IV opioids. The panel made a conditional recommendation against the use of weight-based IV ketamine in combination with weight-based IV opioids versus weight-based IV opioids alone. The panel considered the use of oral analgesics and a conditional recommendation was made for either oral APAP or oral NSAIDs when the oral route of administration was preferred. Given the lack of a supporting evidence base, the panel was unable to make recommendations for the use of nitrous oxide versus IV opioids, or for IV ketamine in combination with IV opioids versus IV ketamine alone. Taken together, the recommendations emphasize that EMS medical directors and EMS clinicians have a variety of effective options for the management of moderate to severe pain in addition to opioids when designing patient care guidelines and caring for patients suffering from acute pain.

  View details for DOI 10.1080/10903127.2021.2018073

  View details for Web of Science ID 000746765200001

  View details for PubMedID 34928760

• Design of a novel clinical trial of prehospital pediatric airway management CLINICAL TRIALS Bosson, N., Hansen, M., Gausche-Hill, M., Lewis, R. J., Wendelberger, B., Shah, M., VanBuren, J. M., Wang, H. E. 2022; 19 (1): 62-70

  Abstract

  Emergency Medical Services personnel are often the first to intervene in the care of critically ill children. Airway management is a fundamental step in prehospital resuscitation, yet there is significant variation in current prehospital airway management practices. Our objective is to present a methodologic approach to determine the optimal strategy for prehospital pediatric airway management. We describe the conceptual premise for the Pediatric Prehospital Airway Resuscitation Trial, a novel Bayesian adaptive sequential platform trial. We developed an innovative design to enable comparison of the three predominant prehospital pediatric airway techniques (bag-mask-ventilation, supraglottic airway insertion, and endotracheal intubation) in three distinct disease groups (cardiac arrest, major trauma, and other respiratory failure). We used a Bayesian statistical approach to provide flexible modeling that can adapt based on prespecified rules according to accumulating trial data with patient enrollment continuing until stopping rules are met. The approach also allows the comparison of multiple interventions in sequence across the different disease states. This Bayesian hierarchical model will be the primary analysis method for the Pediatric Prehospital Airway Resuscitation Trial. The model integrates information across subgroups, a technique known as "borrowing" to generate accurate global and subgroup-specific estimates of treatment effects and enables comparisons of airway intervention arms within the overarching trial. We will use this Bayesian hierarchical linear model that adjusts for subgroup to estimate treatment effects within each subgroup. The model will predict a patient-centered score of 30-day intensive care unit-free survival using arm, subgroup, and emergency medical services agency as predictors. The novel approach of Pediatric Prehospital Airway Resuscitation Trial will provide a feasible method to determine the optimal strategy for prehospital pediatric airway management and may transform the design of future prehospital resuscitation trials.

  View details for DOI 10.1177/17407745211059855

  View details for Web of Science ID 000729496100001

  View details for PubMedID 34875893

• Factors associated with destination of pediatric EMS transports. The American journal of emergency medicine Schmucker, K. A., Camp, E. A., Jones, J. L., Ostermayer, D. G., Shah, M. I. 2021; 50: 360-364

  Abstract

  Pediatric patients comprise 13% of emergency medical services (EMS) transports, and most are transported to general emergency departments (ED). EMS transport destination policies may guide when to transport patients to a children's hospital, especially for medical complaints. Factors that influence EMS providers 'decisions about where to transport children are unknown. Our objective was to evaluate the factors associated with pediatric EMS transports to children's hospitals for medical complaints.We performed a cross-sectional study of a large, urban EMS system over a 12-month period for all transports of patients 0-17 years old. We electronically queried the EMS database for demographic data, medical presentation and management, comorbidities, and documented reasons for choosing destination. Distances to the destination hospital and nearest children's and community hospital (if not the transport destination) were calculated. Univariate and multiple logistic regression analyses were conducted to determine the association between independent variables and the transport destination.We identified 10,065 patients, of which 6982 (69%) were for medical complaints. Of these medical complaints, 3518 (50.4%) were transported to a children's hospital ED. Factors associated with transport to a children's hospital include ALS transport, greater transport distance, protocol determination, developmental delay, or altered consciousness. Factors associated with transport to general EDs were older age, unknown insurance status, lower income, greater distance to children's or community hospital, destination determined by closest facility or diversion, abnormal respiratory rate or blood glucose, psychiatric primary impression, or communication barriers present.We found that younger patient age, EMS protocol requirements, and paramedic scene response may influence pediatric patient transport to both children's and community hospitals. Socioeconomic factors, ED proximity, diversion status, respiratory rate, chief complaints, and communication barriers may also be contributing factors. Further studies are needed to determine the generalizability of these findings to other EMS systems.

  View details for DOI 10.1016/j.ajem.2021.08.047

  View details for PubMedID 34455256

• Impact of Prehospital Pain Management on Emergency Department Management of Injured Children PREHOSPITAL EMERGENCY CARE Harris, M. I., Adelgais, K. M., Linakis, S. W., Magill, C. F., Brazauskas, R., Shah, M. I., Nishijima, D. K., Lowe, G. S., Chadha, K., Chang, T. P., Lerner, E. B., Leonard, J. C., Schwartz, H. P., Gaither, J. B., Studnek, J. R., Browne, L. R. 2023; 27 (1): 1-9

  Abstract

  Provision of analgesia for injured children is challenging for Emergency Medical Services (EMS) clinicians. Little is known about the effect of prehospital analgesia on emergency department (ED) care. We aimed to determine the impact of prehospital pain interventions on initial ED pain scale scores, timing and dosing of ED analgesia for injured patients transported by EMS.This is a planned, secondary analysis of a prospective multicenter cohort of children with actual or suspected injuries transported to one of 11 PECARN-affiliated EDs from July 2019-April 2020. Using Wilcoxon rank sum for continuous variables and chi-square testing for categorical variables, we compared the change in EMS-to-ED pain scores and timing and dosing of ED-administered opioid analgesia in those who did and those who did not receive prehospital pain interventions.We enrolled 474 children with complete prehospital and ED pain management data. Prehospital interventions were performed on 262/474 (55%) of injured children and a total of 88 patients (19%) received prehospital opioids. Children who received prehospital opioids with or without adjunctive non-pharmacologic pain management experienced a greater reduction in pain severity and were more likely to receive ED opioids in higher doses earlier and throughout their ED care. Non-pharmacologic pain interventions alone did not impact ED care.We demonstrate that prehospital opioid analgesia is associated with both a significant reduction in pain severity at ED arrival and the administration of higher doses of opioid analgesia earlier and throughout ED care.

  View details for DOI 10.1080/10903127.2021.2000683

  View details for Web of Science ID 000733296200001

  View details for PubMedID 34734787

• A Novel Use of NEMSIS to Create a PECARN-Specific EMS Patient Registry PREHOSPITAL EMERGENCY CARE Lerner, E., Browne, L. R., Studnek, J. R., Mann, N., Dai, M., Hoffman, C. K., Pilkey, D., Adelgais, K. M., Brown, K. M., Gaither, J. B., Leonard, J. C., Martin-Gill, C., Nishijima, D. K., Owusu Ansah, S., Shah, Z. S., Shah, M. I. 2022; 26 (4): 484-491

  Abstract

  Background: Research networks need access to EMS data to conduct pilot studies and determine feasibility of prospective studies. Combining data across EMS agencies is complicated and costly. Leveraging the National EMS Information System (NEMSIS) to extract select agencies' data may be an efficient and cost-effective method of providing network-level data. Objective: Describe the process of creating a Pediatric Emergency Care Applied Research Network (PECARN) specific NEMSIS data set and determine if these data were nationally representative. Methods: We established data use agreements (DUAs) with EMS agencies participating in PECARN to allow for agency identification through NEMSIS. Using 2019 NEMSIS version 3.4.0 data for EMS events with patients 18 years old and younger, we compared PECARN NEMSIS data to national NEMSIS data. Analyzed variables were selected for their ability to characterize events. No statistical analyses were utilized due to the large sample, instead, differences of ±5% were deemed clinically meaningful. Results: DUAs were established for 19 EMS agencies, creating a PECARN data set with 305,188 EMS activations of which 17,478 (5.7%) were pediatric. Of the pediatric activations, 17,140 (98.1%) were initiated through 9-1-1 and 9,487 (55.4%) resulted in transport by the documenting agency. The national data included 36,288,405 EMS activations of which 2,152,849 (5.9%) were pediatric. Of the pediatric activations 1,704,141 (79.2%) were initiated through 9-1-1 and 1,055,504 (61.9%) were transported by the documenting agency. Age and gender distributions were similar between the two groups, but the PECARN-specific data under-represents Black and Latinx patients. Comparison of EMS provider primary impressions revealed that three of the five most common were similar with injury being the most prevalent for both data sets along with mental/behavioral health and seizure. Conclusion: We demonstrated that NEMSIS can be leveraged to create network specific data sets. PECARN's EMS data were similar to the national data, though racial/ethnic minorities and some primary impressions may be under-represented. Additionally, more EMS activations in PECARN study areas originated through 9-1-1 but fewer were transported by the documenting agency. This is likely related to the type of participating agencies, their ALS response level, and the diversity of the communities they serve.

  View details for DOI 10.1080/10903127.2021.1951407

  View details for Web of Science ID 000677898200001

  View details for PubMedID 34232828

• Pediatric Simulation-Based Prehospital Training Course in Botswana. Journal of education & teaching in emergency medicine Glomb, N. W., Rus, M. C., Kosoko, A. A., Saha, S., Murphy, K., Doughty, C. B., Galapi, C., Laba, B., Shah, M. I. 2021; 6 (3): C64-C189

  Abstract

  This simulation-based training focuses on the most common and high risk pediatric prehospital scenarios in low- and middle-income countries (LMIC). The curriculum was developed based on a needs assessment to train Ministry of Health and Wellness (MOHW) prehospital providers in Botswana specifically for pediatric resuscitation and could be used for emergency medical services (EMS) providers in other LMIC. After participating in this curriculum, providers should enhance their assessment and interventions in acutely ill pediatric prehospital patients.The entire course was designed to be presented over two days with 6-8 hours of instruction each day.In recent years, prehospital medicine has shown continued growth in LMICs, specifically in Sub-Saharan Africa. As these programs develop focused training for the pediatric population, equipping the workforce with pediatric resuscitation skills is essential. A few years after its inception, the Botswana MOHW identified deficiencies in their current training program and sought external expertise and educational training. We partnered with the MOHW to create and implement a novel, prehospital simulation curriculum to teach pediatric resuscitation to prehospital providers. Our aim was to create a curriculum based on the needs of the community that could also be implemented in other similar resource-limited settings. This course included didactic sessions, five simulation scenarios using low fidelity mannequins and three pediatric-focused skill sessions. This program was found to be effective based on statistically significant improvement in written and simulation post-test scores.The objective of this educational project was to design, implement, and evaluate a curriculum relevant to an EMS system based in a LMIC, so that it could be a basis for curricula for use in similar contexts. The educational goal is to improve prehospital providers performance in common pediatric resuscitations.The educational methods used in this curriculum included simulation using rapid cycle deliberate practice (RCDP), didactic lectures, and hands on skills training for common pediatric scenarios. Outcomes were measured by comparing performance on written and simulation-based pre-and post-tests.Participants completed written and simulation-based pre- and post-tests covering the concepts taught in the curriculum. Continuous variables (written and simulation test scores) were compared between two dependent groups (pre- and post-trainings) using paired t-tests.Mean written test scores increased by 11%, from 75% to 86% (p<0.0001), while mean simulated test scores increased by 22% (from 56% to 78 % (p<0.0001).The curriculum we developed focused on high-yield pediatric skills based on the needs of the Botswana MOHW EMS program. We believe simulation training was an excellent and effective method for this type of training. We specifically designed RCDP scenarios for the training, due to the limited experience of the prehospital providers at that time. RCDP offers ample opportunities for feedback with immediate practice and improvement. Trainees demonstrated retention of knowledge and improved performance in simulation-based testing. The overall satisfaction level of the trainees was high and suggests additional training would be beneficial and desired. Additionally, as the results of our needs assessment mirrored common chief complaints in other LMIC countries in Sub-Saharan Africa1,2 we feel that this curriculum can be utilized and adopted with minor modifications in other LMIC settings, particularly where EMS programs are developing and in circumstances where few EMS providers have had extensive field experience.Respiratory distress, asthma, dehydration, hypovolemic shock, hypoglycemia, seizure, toxic ingestion, newborn resuscitation, precipitous delivery, traumatic injury, EMS, Botswana, global health, collaboration, rapid cycle deliberate practice (RCDP), medical simulation.

  View details for DOI 10.21980/J8306S

  View details for PubMedID 37465077

  View details for PubMedCentralID PMC10332686

• Critical Factors in Planning a Pediatric Prehospital Airway Trial PREHOSPITAL EMERGENCY CARE Hansen, M., Bosson, N., Gausche-Hill, M., Shah, M. I., VanBuren, J. M., Wendelberger, B., Wang, H. 2022; 26 (4): 476-483

  Abstract

  Objective: The objective of this study was to assess factors influencing the design of a pediatric prehospital airway management trial, including minimum clinically significant differences for three clinical subgroups. Methods: We conducted a virtual consensus-conference among U.S. emergency medical services (EMS) agency medical directors and researchers in the Fall of 2020. This included (1) a preconference survey, (2) an interactive live videoconference, and (3) a postconference survey. Participants were identified through co-investigator relationships and by surveying "The Eagles," a consortium of medical directors from large urban EMS systems and, subsequently, through follow up email contact based on survey responses. Results: Twenty-seven of the 34 (80%) EMS agencies we invited responded to the prewebinar survey. Of the 27 agencies, 27 (100%) use BMV, 19 (70%) use endotracheal intubation (ETI), 21 (78%) use supraglottic airways (SGA). SGA use included 14 (52%) who use the iGel, 8 (30%) who use the King laryngeal tube (LT), and 2 (7%) who use a laryngeal mask airway (LMA). Three agencies use more than one of the available SGAs. Twenty (74%) of the EMS agencies indicated they had access to an SGA suitable for pediatric patients, and 9 (33%) agencies have access to pediatric video laryngoscopy. The majority of agencies indicated that the minimum clinically significant difference for survival to change practice was 1% for cardiac arrest patients with a baseline survival assumption of 7%, 4% for respiratory failure with a baseline survival assumption of 73%, and 3% for trauma with a baseline survival assumption of 42%. Overall, these agencies responded that BVM vs. SGA is the most important comparison that would change their practice. Conclusions: This virtual consensus conference provided a new perspective on current airway management practice and identified specific factors likely to drive change in pediatric prehospital airway management. This information will be leveraged in future trial design to ensure impactful clinical trials.

  View details for DOI 10.1080/10903127.2021.1918808

  View details for Web of Science ID 000656732700001

  View details for PubMedID 33886422

• Pediatric Readiness in Emergency Medical Services Systems. Prehospital emergency care Moore, B., Shah, M. I., Owusu-Ansah, S., Gross, T., Brown, K., Gausche-Hill, M., Remick, K., Adelgais, K., Lyng, J., Rappaport, L., Snow, S., Wright-Johnson, C., Leonard, J. C. 2020; 24 (2): 175-179

  Abstract

  This is a joint policy statement from the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Services Physicians, and National Association of Emergency Medical Technicians on pediatric readiness in emergency medical services systems.

  View details for DOI 10.1080/10903127.2019.1685614

  View details for PubMedID 31854223

• Educational impact of a pilot paediatric simulation-based training course in Botswana. BMJ simulation & technology enhanced learning Glomb, N. W., Shah, M. I., Kosoko, A. A., Doughty, C. B., Galapi, C., Laba, B., Rus, M. C. 2020; 6 (5): 279-283

  Abstract

  As emergency medical services (EMS) systems develop globally in resource-limited settings, equipping providers with paediatric training is essential. Low-fidelity simulation-based training is an effective modality for training healthcare workers, though limited data exist on the impact of such training programmes. The objective of this study was to evaluate the paediatric portion of a simulation-based curriculum for prehospital providers in Botswana.This was a prospective cohort study of EMS providers from more populated regions of Botswana, who attended a 2-day training that included didactic lectures, hands-on skills stations and low-fidelity simulation training. We collected data on participant self-efficacy with paediatric knowledge and skills and performance on both written and simulation-based tests. Self-efficacy and test data were analysed, and qualitative course feedback was summarised.Thirty-one EMS providers participated in the training. Median self-efficacy levels increased for 13/15 (87%) variables queried. The most notable improvements were observed in airway management, newborn resuscitation and weight estimation. Mean written test scores increased by 10.6%, while mean simulation test scores increased by 21.5% (p<0.0001). One hundred per cent of the participants rated the course as extremely useful or very useful.We have demonstrated that a low-fidelity simulation-based training course based on a rigorous needs assessment may enhance short-term paediatric knowledge and skills for providers in a developing EMS system in a limited-resource setting. Future studies should focus on studying larger groups of learners in similar settings, especially with respect to the impact of educational programmes like these on real-world patient outcomes.

  View details for DOI 10.1136/bmjstel-2019-000501

  View details for PubMedID 35517398

  View details for PubMedCentralID PMC8936647

• Multicenter Evaluation of Prehospital Seizure Management in Children PREHOSPITAL EMERGENCY CARE Shah, M. I., Ostermayer, D. G., Browne, L. R., Studnek, J. R., Carey, J. M., Stanford, C., Fumo, N., Lerner, E. 2021; 25 (4): 475-486

  Abstract

  Seizures are a common reason why emergency medical services (EMS) transports children by ambulance. Timely seizure cessation prevents neurologic morbidity, respiratory compromise, and mortality. Implementing recommendations from an evidence-based pediatric prehospital guideline may enhance timeliness of seizure cessation and optimize medication dosing.We compared management of pediatric prehospital seizures across several EMS systems after protocol revision consistent with an evidence-based guideline.Using a retrospective, cross-sectional approach, we evaluated actively seizing patients (0-17 years old) EMS transported to a hospital before and after modifying local protocols to include evidence-based recommendations for seizure management in three EMS agencies. We electronically queried and manually abstracted both EMS and hospital data at each site to obtain information about patient demographics, medications given, seizure cessation and recurrence, airway interventions, access obtained, and timeliness of care. The primary outcome of the study was the appropriate administration of midazolam based on route and dose. We analyzed these secondary outcomes: frequency of seizure activity upon emergency department (ED) arrival, frequency of respiratory failure, and timeliness of care.We analyzed data for 533 actively seizing patients. Paramedics were more likely to administer at least one dose of midazolam after the protocol updates [127/208 (61%) vs. 232/325 (71%), p = 0.01, OR = 1.60 (95% CI: 1.10-2.30)]. Paramedics were also more likely to administer the first midazolam dose via the preferred intranasal (IN) or intramuscular (IM) routes after the protocol change [(63/208 (49%) vs. 179/325 (77%), p < 0.001, OR = 3.24 (2.01-5.21)]. Overall, paramedics administered midazolam approximately 14 min after their arrival, gave an incorrect weight-based dose to 130/359 (36%) patients, and gave a lower than recommended dose to 94/130 (72%) patients. Upon ED arrival, 152/533 (29%) patients had a recurrent or persistent seizure. Respiratory failure during EMS care or subsequently in the ED occurred in 90/533 (17%) patients.Implementation of an evidence-based seizure protocol for EMS increased midazolam administration. Patients frequently received an incorrect weight-based dose. Future research should focus on optimizing administration of the correct dose of midazolam to improve seizure cessation.

  View details for DOI 10.1080/10903127.2020.1788194

  View details for Web of Science ID 000550088200001

  View details for PubMedID 32589502

• Focused Research Infrastructure for Postgraduate Pediatric Emergency Medicine Fellows Increases Dissemination of Scholarly Work. AEM education and training Cruz, A. T., Doughty, C. B., Hsu, D. C., Chumpitazi, C. E., Sampayo, E. M., Meskill, S. D., Shah, M. I. 2020; 4 (3): 231-238

  Abstract

  Many fellows in clinically driven subspecialties may have difficulty completing and publishing their scholarly projects due to lack of prior experience in research, selection of projects that are difficult to complete during fellowship, or mentorship challenges. This may be particularly true in pediatric emergency medicine (PEM) because research time may be longitudinally integrated with clinical rotations, rather than blocked as is common in other subspecialties. We describe the creation and outcomes of a structured program to increase academic productivity of PEM fellows.This was a retrospective cohort study of scholarly productivity (publications in peer-reviewed journals, presentation at national meetings) for PEM fellows over 17 years in one fellowship program, before and after the implementation of a structured program. We reviewed obstacles to publication for prior fellow projects when developing the curriculum. Our multifaceted program consisted of milestone development, four in-person committee meetings, and abstract and manuscript development workshops. We utilized existing faculty members, most of whom were junior faculty, as committee members. Our primary outcome was the percentage of fellows who were first authors for peer-reviewed publications for their fellowship projects. National conference presentations were the secondary outcome.Data for 76 PEM fellows were eligible for analysis: 44 (58%) before and 32 after programmatic implementation. There was a statistically significant increase in the percentage of fellows who published their studies (32% vs. 63%; odds ratio [OR] = 3.6, 95% confidence interval [CI] = 1.4 to 9.3) after programmatic implementation. There were no differences in conference presentations (45% vs. 63%; OR = 2.0, 95% CI = 0.8-5.1) after implementation.Utilizing a small group of existing, predominantly junior faculty members, we created a structured program that enhanced PEM fellows' scholarly productivity and increased publications. We believe that this model is sustainable for and generalizable to other PEM fellowship programs.

  View details for DOI 10.1002/aet2.10402

  View details for PubMedID 32704592

  View details for PubMedCentralID PMC7369492

• Evaluation of Hydrocodone/Acetaminophen for Pediatric Laceration Repair: A Randomized Trial. Plastic and reconstructive surgery Chumpitazi, C. E., Caviness, A. C., Grawe, G. H., Camp, E. A., Shah, M. I. 2020; 145 (1): 126e-134e

  Abstract

  Laceration repair is a common procedure, and causes pain and distress in children. The purpose of this study was to measure the effect of hydrocodone/acetaminophen elixir in reducing both pain and anxiety in children undergoing sutured laceration repair in the emergency department.The authors conducted a randomized, double-blinded, placebo-controlled trial in children aged 2 to 17 years, stratified by age younger than 8 years, with topical lidocaine-treated lacerations requiring sutured repair in the emergency department. The primary outcome was pain score at 5 minutes of laceration repair. Secondary outcomes included progression to procedural sedation and anxiety scores in older children.Eighty-five children were randomized, 43 to the hydrocodone/acetaminophen group and 42 to the placebo group. Median 5-minute pain scores in children aged 2 to 7 years were significantly lower in the medication group (5.0; interquartile range, 4.0 to 6.50) compared with the placebo group (7.0; interquartile range, 5.25 to 10.0; p = 0.01). Three patients (12 percent) in the placebo group proceeded to procedural sedation. For children aged 8 to 17 years, there was no significant difference in pain scores between the treatment (0.5; interquartile range, 0.0 to 0.1; p = 0.81) and placebo groups (0.1; interquartile range, 0.01 to 0.4) or in anxiety scores using the State-Trait Anxiety Inventory for Children.Adjuvant oral hydrocodone/acetaminophen is more effective than placebo in reducing pain in children younger than 8 years undergoing topical lidocaine-treated laceration repair, but it does not decrease pain or anxiety in older children.Therapeutic, II.

  View details for DOI 10.1097/PRS.0000000000006383

  View details for PubMedID 31881621

• Pediatric Readiness in Emergency Medical Services Systems. Annals of emergency medicine Moore, B., Shah, M. I., Owusu-Ansah, S., Gross, T., Brown, K., Gausche-Hill, M., Remick, K., Adelgais, K., Lyng, J., Rappaport, L., Snow, S., Wright-Johnson, C., Leonard, J. C. 2020; 75 (1): e1-e6

  View details for DOI 10.1016/j.annemergmed.2019.09.012

  View details for PubMedID 31866028

• Pediatric Readiness in Emergency Medical Services Systems. Pediatrics Owusu-Ansah, S., Moore, B., Shah, M. I., Gross, T., Brown, K., Gausche-Hill, M., Remick, K., Adelgais, K., Rappaport, L., Snow, S., Wright-Johnson, C., Leonard, J. C., Lyng, J., Fallat, M. 2020; 145 (1)

  Abstract

  Ill and injured children have unique needs that can be magnified when the child's ailment is serious or life-threatening. This is especially true in the out-of-hospital environment. Providing high-quality out-of-hospital care to children requires an emergency medical services (EMS) system infrastructure designed to support the care of pediatric patients. As in the emergency department setting, it is important that all EMS agencies have the appropriate resources, including physician oversight, trained and competent staff, education, policies, medications, equipment, and supplies, to provide effective emergency care for children. Resource availability across EMS agencies is variable, making it essential that EMS medical directors, administrators, and personnel collaborate with outpatient and hospital-based pediatric experts, especially those in emergency departments, to optimize prehospital emergency care for children. The principles in the policy statement "Pediatric Readiness in Emergency Medical Services Systems" and this accompanying technical report establish a foundation on which to build optimal pediatric care within EMS systems and serve as a resource for clinical and administrative EMS leaders.

  View details for DOI 10.1542/peds.2019-3308

  View details for PubMedID 31857378

• Pediatric Readiness in Emergency Medical Services Systems. Pediatrics Moore, B., Shah, M. I., Owusu-Ansah, S., Gross, T., Brown, K., Gausche-Hill, M., Remick, K., Adelgais, K., Lyng, J., Rappaport, L., Snow, S., Wright-Johnson, C., Leonard, J. C. 2020; 145 (1)

  Abstract

  This is a joint policy statement from the American Academy of Pediatrics, American College of Emergency Physicians, Emergency Nurses Association, National Association of Emergency Medical Services Physicians, and National Association of Emergency Medical Technicians on pediatric readiness in emergency medical services systems.

  View details for DOI 10.1542/peds.2019-3307

  View details for PubMedID 31857380

• Paramedic-Identified Enablers of and Barriers to Pediatric Seizure Management: A Multicenter, Qualitative Study PREHOSPITAL EMERGENCY CARE Carey, J. M., Studnek, J. R., Browne, L. R., Ostermayer, D. G., Grawey, T., Schroter, S., Lerner, E., Shah, M. 2019; 23 (6): 870-881

  Abstract

  Seizures have the potential to cause significant morbidity and mortality, and are a common reason EMS are requested for a child. An evidence-based guideline (EBG) for pediatric prehospital seizures was published and has been implemented as protocol in multiple EMS systems. Knowledge translation and protocol adherence in medicine can be incomplete. In EMS, systems-based factors and providers' attitudes and beliefs may contribute to incomplete knowledge translation and protocol implementation.The purpose of this study was to identify paramedic attitudes and beliefs regarding pediatric seizure management and regarding potential barriers to and enablers of adherence to evidence-based pediatric seizure protocols in multiple EMS systems.This was a qualitative study utilizing semi-structured interviews of paramedics who recently transported actively seizing 0-17 year-old patients in three different urban EMS systems. Interviewers explored the providers' decision-making during their recent case and regarding seizures in general. Interview questions explored barriers to and enablers of protocol adherence. Two investigators used the grounded theory approach and constant comparison to independently analyze transcribed interview recordings until thematic saturation was reached. Findings were validated with follow-up member-checking interviews.Several themes emerged from the 66 interviewed paramedics. Enablers of protocol adherence included point-of-care references, the availability of different routes for midazolam, and availability of online medical control. Systems-level barriers included equipment availability, controlled substance management, infrequent pediatric training, and protocol ambiguity. Provider-level barriers included concerns about respiratory depression, provider fatigue, preferences for specific routes, febrile seizure perceptions, and inaccurate methods of weight estimation. Paramedics suggested system improvements to address dose standardization, protocol clarity, simplified controlled substance logistics, and equipment availability.Paramedics identified enablers of and barriers to adherence to evidence-based pediatric seizure protocols. The identified barriers existed at both the provider and systems levels. Paramedics identified multiple potential solutions to overcome several barriers to protocol adherence. Future research should focus on using the findings of this study to revise seizure protocols and to deploy measures to improve protocol implementation. Future research should also analyze process and outcome measures before and after the implementation of revised seizure protocols informed by the findings of this study.

  View details for DOI 10.1080/10903127.2019.1595234

  View details for Web of Science ID 000493613200014

  View details for PubMedID 30917730

• Impact of an Extraglottic Device on Pediatric Airway Management in an Urban Prehospital System. The western journal of emergency medicine Ostermayer, D. G., Camp, E. A., Langabeer, J. R., Brown, C. A., Mondragon, J., Persse, D. E., Shah, M. I. 2019; 20 (6): 962-969

  Abstract

  Prehospital pediatric endotracheal intubation has lower first-pass success rates compared to adult intubations and in general may not offer a survival benefit. Increasingly, emergency medical services (EMS) systems are deploying prehospital extraglottic airways (EGA) for primary pediatric airway management, yet little is known about their efficacy. We evaluated the impact of a pediatric prehospital airway management protocol change, inclusive of EGAs, on airway management and patient outcomes in children in cardiac arrest or respiratory failure.Using data from a large, metropolitan, fire-based EMS service, we performed an observational study of pediatric patients with respiratory failure or cardiac arrest who were transported by EMS before and after implementation of an evidence-based airway management protocol inclusive of the addition of the EGA. The primary outcome was change in frequency of intubation attempts when paired with an initial EGA. Secondary outcomes included EGA and intubation success rates and patient survival to hospitalization and discharge.We included 265 patients age <16 years old, with 142 pre- and 123 post-protocol change. Patient demographics and event characteristics were similar between groups. Intubation attempts declined from 79.6% pre- to 44.7% (p<0.01) post-protocol change. In patients with an intubation attempt, overall intubation success declined from 81.4% to 63.6% (p<0.01). Post-protocol change, an EGA was attempted in 52.8% of patients with 95.4% success.Implementation of an evidenced-based airway management algorithm for pediatric patients, inclusive of an EGA device for all age groups, was associated with fewer prehospital intubations. Intubation success may be negatively impacted due to decreases in procedural frequency.

  View details for DOI 10.5811/westjem.2019.8.44464

  View details for PubMedID 31738725

  View details for PubMedCentralID PMC6860396

• Validity of the Pediatric Early Warning Score and the Bedside Pediatric Early Warning Score in Classifying Patients Who Require the Resources of a Higher Level Pediatric Hospital PREHOSPITAL EMERGENCY CARE Studnek, J. R., Browne, L. R., Shah, M., Fumo, N., Hansen, M., Lerner, E. 2020; 24 (3): 341-348

  Abstract

  Introduction: The pediatric early warning score (PEWS) and the bedside pediatric early warning score (BPEWS) are validated tools that help determine the need for critical care in children with acute medical conditions. These tools could be used by EMS and have not been evaluated outside of the hospital. This study retrospectively tested the validity of these tools in the prehospital setting to identify children who needed a hospital with higher level pediatric resources. Methods: This was a multi-center retrospective validation of screening tools using prehospital and in-hospital data obtained from 3 EMS agencies. EMS patient records from April 1, 2013 to April 30, 2015 were used to identify subjects for this analysis. Pediatric patients were retrospectively classified using the PEWS based on the clinical information documented in the EMS medical record. Those with PEWS scores greater than 4 were matched to a subject with scores less than 4 based on age, gender, and paramedic primary impression. Hospital medical record review was then used to determine whether the patient required a hospital with higher level pediatric resources. These classifications were used to calculate sensitivity, specificity, and resultant 95% confidence intervals. The analysis was repeated for included subjects who had sufficient data to calculate BPEWS. Results: There were 386 patients enrolled. A PEWS ≥ 4 demonstrated a sensitivity of 62.8 (95% CI 53.6-71.4) and a specificity of 55.9 (95% CI 49.6-61.9) in identifying a patient who required a hospital with higher level pediatric resources. There were 44 pairs of patients that had sufficient EMS data documented to calculate a BPEWS. A BPEWS ≥ 7 demonstrated a sensitivity of 46.4 (95% CI 27.5-66.1) and a specificity of 76.7 (95% CI 64.0-86.6) to correctly classify a patient who required a hospital with higher level pediatric resources. Conclusion: In the prehospital setting neither PEWS nor BPEWS exhibited sufficient sensitivity for clinical use to accurately identify children who need a hospital with higher level pediatric resources. Further research should be conducted to identify variables that are captured by prehospital care providers and are associated with children who need a hospital with higher level pediatric resources.

  View details for DOI 10.1080/10903127.2019.1645924

  View details for Web of Science ID 000485493500001

  View details for PubMedID 31339430

• Evaluating a Novel Simulation Course for Prehospital Provider Resuscitation Training in Botswana. The western journal of emergency medicine Kosoko, A. A., Glomb, N. W., Laba, B., Galapi, C., Shah, M. I., Rus, M. C., Doughty, C. B. 2019; 20 (5): 731-739

  Abstract

  In 2012, Botswana embarked on an organized public approach to prehospital medicine. One goal of the Ministry of Health (MOH) was to improve provider education regarding patient stabilization and resuscitation. Simulation-based instruction is an effective educational strategy particularly for high-risk, low-frequency events. In collaboration with partners in the United States, the team created a short, simulation-based course to teach and update prehospital providers on common field responses in this resource-limited setting. The objective of this study was to evaluate an educational program for Botswanan prehospital providers via written and simulation-based examinations.We developed a two-day course based on a formal needs assessment and MOH leadership input. The subject matter of the simulation scenarios represented common calls to the prehospital system in Botswana. Didactic lectures and facilitated skills training were conducted by U.S. practitioners who also served as instructors for a rapid-cycle, deliberate practice simulation education model and simulation-based testing scenarios. Three courses, held in three cities in Botswana, were offered to off-duty MOH prehospital providers, and the participants were evaluated using written multiple-choice tests, videotaped traditional simulation scenarios, and self-efficacy surveys.Collectively, 31 prehospital providers participated in the three courses. The mean scores on the written pretest were 67% (standard deviation [SD], 10) and 85% (SD, 7) on the post-test (p < 0.001). The mean scores for the simulation were 42% (SD, 14.2) on the pretest and 75% (SD, 11.3) on the post-test (p < 0.001). Moreover, the intraclass correlation coefficient scores between reviewers were highly correlated at 0.64 for single measures and 0.78 for average measures (p < 0.001 for both). Twenty-one participants (68%) considered the course "extremely useful."Botswanan prehospital providers who participated in this course significantly improved in both written and simulation-based performance testing. General feedback from the participants indicated that the simulation scenarios were the most useful and enjoyable aspects of the course. These results suggest that this curriculum can be a useful educational tool for teaching and reinforcing prehospital care concepts in Botswana and may be adapted for use in other resource-limited settings.

  View details for DOI 10.5811/westjem.2019.6.41639

  View details for PubMedID 31539330

  View details for PubMedCentralID PMC6754192

• Ready for Children: Assessing Pediatric Care Coordination and Psychomotor Skills Evaluation in the Prehospital Setting PREHOSPITAL EMERGENCY CARE Hewes, H. A., Ely, M., Richards, R., Shah, M. I., Busch, S., Pilkey, D., Hert, K., Olson, L. M. 2019; 23 (4): 510-518

  Abstract

  Objective: Pediatric patients represent low frequency but potentially high-risk encounters for emergency medical services (EMS) providers. Scant information is available from EMS agencies on the frequency of pediatric skill evaluation and the presence of pediatric emergency care coordination, both which may help EMS systems optimize care for children. The objective of our study was to assess the frequency and type of methods used to assess psychomotor skills competency using pediatric-specific equipment and pediatric care coordination in EMS ground transport agencies. Methods: A web-based assessment was sent to EMS agency directors in 58 states/territories to determine the presence of pediatric care coordination defined as an individual who oversees pediatric issues (Pediatric Care Coordinator or PECC) and the process for evaluating psychomotor skills of EMS providers using of pediatric equipment. Basic demographic information of each agency was collected. Descriptive statistics, odds ratios, and 95% confidence intervals were used for analyses. Results: The response rate was 78% (8,166/10,463 agencies). Almost 80% of agencies respond to fewer than 100 pediatric calls a year; over half of the agencies are located in urban areas and provide Advanced Life Support care. Twenty-three percent (23%) of EMS agency administrators report having a PECC and 28% have plans or interest in adding one. Of those agencies with a PECC, 26% report sharing the position among several agencies. Almost half (47%) of EMS agencies evaluate pediatric psychomotor skills at least twice a year. Agencies with a PECC, those with a medium to medium high pediatric call volume and agencies located in urban areas are more likely to evaluate psychomotor skills at least twice a year. Conclusions: Although few EMS agencies currently have a PECC, there is interest among EMS agency administrators to integrate one into their system. Pediatric-specific psychomotor skills testing is more common in EMS agencies that respond to a higher pediatric call volume and have a PECC. For EMS agencies that infrequently treat children, the presence of a PECC may enhance the frequency of pediatric psychomotor skills evaluation. The presence of a PECC can potentially increase provider confidence and safety for all pediatric prehospital patients regardless of volume and location.

  View details for DOI 10.1080/10903127.2018.1542472

  View details for Web of Science ID 000473517000009

  View details for PubMedID 30380953

• Pediatric Cervical Spine Clearance A Consensus Statement and Algorithm from the Pediatric Cervical Spine Clearance Working Group JOURNAL OF BONE AND JOINT SURGERY-AMERICAN VOLUME Herman, M. J., Brown, K. O., Sponseller, P. D., Phillips, J. H., Petrucelli, P. M., Parikh, D. J., Mody, K. S., Leonard, J. C., Moront, M., Brockmeyer, D. L., Anderson, R. E., Alder, A. C., Anderson, J. T., Bernstein, R. M., Booth, T. N., Braga, B. P., Cahill, P. J., Joglar, J. M., Martus, J. E., Nesiama, J. O., Pahys, J. M., Rathjen, K. E., Riccio, A. I., Schulz, J. F., Stans, A. A., Shah, M. I., Warner, W. C., Yaszay, B. 2019; 101 (1): e1

  View details for DOI 10.2106/JBJS.18.00217

  View details for Web of Science ID 000458568900001

  View details for PubMedID 30601421

• Needs Assessment for Simulation Training for Prehospital Providers in Botswana. Prehospital and disaster medicine Glomb, N. W., Kosoko, A. A., Doughty, C. B., Rus, M. C., Shah, M. I., Cox, M., Galapi, C., Parkes, P. S., Kumar, S., Laba, B. 2018; 33 (6): 621-626

  Abstract

  In June 2012, the Botswana Ministry of Health and Wellness (MOHW; Gaborone, Botswana) initiated a national Emergency Medical Services (EMS) system in response to significant morbidity and mortality associated with prehospital emergencies. The MOHW requested external expertise to train its developing workforce. Simulation-based training was planned to equip these health care providers with clinical knowledge, procedural skills, and communication techniques.The objective of this study was to assess the educational needs of the pioneer Botswana MOHW EMS providers based on retrospective EMS logbook review and EMS provider feedback to guide development of a novel educational curriculum.Data were abstracted from a representative sample of the Gaborone, Botswana MOHW EMS response log from 2013-2014 and were quantified into the five most common call types for both adults and children. Informal focus groups with health professionals and EMS staff, as well as surveys, were used to rank common response call types and self-perceived educational needs.Based on 1,506 calls, the most common adult response calls were for obstetric emergencies, altered mental status, gastrointestinal/abdominal pain, trauma, gynecological emergencies, and cardiovascular and respiratory distress-related emergencies. The most common pediatric response calls were for respiratory distress, gastrointestinal complaints/dehydration, trauma and musculoskeletal injuries, newborn delivery, seizures, and toxic ingestion/exposure. The EMS providers identified these same chief complaints as priorities for training using the qualitative approach. A locally relevant, simulation-based curriculum for the Botswana MOHW EMS system was developed and implemented based on these data.Trauma, respiratory distress, gastrointestinal complaints, and puerperal/perinatal emergencies were common conditions for all age groups. Other age-specific conditions were also identified as educational needs based on epidemiologic data and provider feedback. This needs assessment may be useful when designing locally relevant EMS curricula in other low-income and middle-income countries. GlombNW, KosokoAA, DoughtyCB, RusMC, ShahMI, CoxM, GalapiC, ParkesPS, KumarS, LabaB. Needs assessment for simulation training for prehospital providers in Botswana. Prehosp Disaster Med. 2018;33(6):621-626.

  View details for DOI 10.1017/S1049023X18001024

  View details for PubMedID 30419999

• Consensus-based Criterion Standard for the Identification of Pediatric Patients Who Need Emergency Medical Services Transport to a Hospital with Higher-level Pediatric Resources. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Studnek, J. R., Lerner, E. B., Shah, M. I., Browne, L. R., Brousseau, D. C., Cushman, J. T., Dayan, P. S., Drayna, P. C., Drendel, A. L., Gray, M. P., Kahn, C. A., Meyer, M. T., Shah, M. N., Stanley, R. M. 2018; 25 (12): 1409-1414

  Abstract

  Emergency medical services (EMS) providers must be able to identify the most appropriate destination facility when treating children with potentially severe medical illnesses. Currently, no validated tool exists to assist EMS providers in identifying children who need transport to a hospital with higher-level pediatric care. For such a tool to be developed, a criterion standard needs to be defined that identifies children who received higher-level pediatric medical care.The objective was to develop a consensus-based criterion standard for children with a medical complaint who need a hospital with higher-level pediatric resources.Eleven local and national experts in EMS, emergency medicine (EM), and pediatric EM were recruited. Initial discussions identified themes for potential criteria. These themes were used to develop specific criteria that were included in a modified Delphi survey, which was electronically delivered. The criteria were refined iteratively based on participant responses. To be included, a criterion required at least 80% agreement among participants. If an item had less than 50% agreement, it was removed. A criterion with 50% to 79% agreement was modified based on participant suggestions and included on the next survey, along with any new suggested criteria. Voting continued until no new criteria were suggested and all criteria received at least 80% agreement.All 11 recruited experts participated in all seven voting rounds. After the seventh vote, there was agreement on each item and no new criteria were suggested. The recommended criterion standard included 13 items that apply to patients 14 years old or younger. They included IV antibiotics for suspicion of sepsis or a seizure treated with two different classes of anticonvulsive medications within 2 hours, airway management, blood product administration, cardiopulmonary resuscitation, electrical therapy, administration of specific IV/IO drugs or respiratory assistance within 4 hours, interventional radiology or surgery within 6 hours, intensive care unit admission, specific comorbid conditions with two or more abnormal vital signs, and technology-assisted children seen for device malfunction.We developed a 13-item consensus-based criterion standard definition for identifying children with medical complaints who need the resources of a hospital equipped to provide higher-level pediatric services. This criterion standard will allow us to create a tool to improve pediatric patient care by assisting EMS providers in identifying the most appropriate destination facility for ill children.

  View details for DOI 10.1111/acem.13625

  View details for PubMedID 30281884

• Determinants of Pediatric EMS Utilization in Children with High-Acuity Conditions PREHOSPITAL EMERGENCY CARE Quinones, C., Shah, M. I., Cruz, A. T., Graf, J. M., Mondragon, J. A., Camp, E. A., Reddy, P., Sampayo, E. M. 2018; 22 (6): 676-690

  Abstract

  Underutilization of emergency medical services (EMS) for children with high-acuity conditions is poorly understood. Our objective was to identify differences in demographic factors and describe caregivers' knowledge, beliefs, and attitudes regarding EMS utilization for children with high-acuity conditions.This was a mixed-methods study of children with high acuity conditions, defined as requiring immediate medical or surgical intervention and intensive care admission, over a one year period. Demographic data were collected through a retrospective chart review. Qualitative analysis of semi-structured interviews from a purposive sample of caregivers was conducted until thematic saturation was achieved.Three hundred seventy-four charts were reviewed; 19 caregivers were interviewed (17 in-person, 2 via telephone). The 232 (62%) children not arriving by EMS tended to be younger (1.58 years vs. 2.31 years, p = 0.02), privately insured (30% vs. 19%, p = 0.04), and lived further from the hospital (16.80 miles vs. 12.45 miles, p = 0.001). Patient gender, ethnicity, comorbidities and caregiver language were not associated with EMS underutilization. Immediate invasive medical interventions were more often required for EMS utilizers (85% vs. 60%, p < 0.001). EMS utilizers were more likely to require intubation (78% vs. 47%, p < 0.001) and cardiopulmonary resuscitation (CPR) (26% vs. 2%, p < 0.001), and had shorter hospital stays (4.70 vs. 8.16 days; p-value < 0.001). Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Three principal themes determined EMS utilization: expectations, knowledge, and perceived barriers. Caretakers expected EMS would provide timely, safe transportation that expedited medical care and emotional support. Medical knowledge and prior experience with EMS influenced decision-making about arrival mode. Timeliness, cost, socioeconomic and demographic characteristics, loss of autonomy, and the logistics of EMS activation and transport were the most commonly reported barriers.Young age, private insurance status, and greater distance from the hospital were associated with EMS underutilization. Understanding caregiver expectations, knowledge, and perceived barriers may have important implications for the use of EMS for children. These findings reveal opportunities for improved public education on EMS systems to enhance appropriate EMS utilization for children with high acuity conditions.

  View details for DOI 10.1080/10903127.2018.1445330

  View details for Web of Science ID 000452485300004

  View details for PubMedID 29565717

• Multicenter Analysis of Transport Destinations for Pediatric Prehospital Patients. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Lerner, E. B., Studnek, J. R., Fumo, N., Banerjee, A., Arapi, I., Browne, L. R., Ostermayer, D. G., Reynolds, S., Shah, M. I. 2018

  Abstract

  Although all emergency departments (EDs) should be ready to treat children, some may have illnesses or injuries that require higher-level pediatric resources that are not available at all hospitals. There are no national guidelines for emergency medical services (EMS) providers about when to directly transport children to hospitals with higher-level pediatric resources, with the exception of severe trauma. Variability exists in EMS protocols about when children warrant transport to hospitals with higher-level pediatric care.The objective was to determine how frequently pediatric patients are transported by EMS to hospitals with higher-level pediatric resources and to evaluate distribution patterns based on illness and injury severity.We conducted a retrospective analysis of all pediatric (age 0-18 years) transports in three large EMS systems between November 2014 and November 2016. Each community had a hospital with higher-level pediatric resources that was within a 30-minute transport time from any location. Patients were included if they were transported by ground ambulance and the request originated in the 9-1-1 system. We assessed the frequency of transports to a hospital with higher-level pediatric resources. Data were stratified by chief complaint of illness or injury and severity. Potential risk for severe injury was defined as meeting the physiologic step of the field triage guidelines and potential risk for severe illness was defined as having an abnormal vital sign after adjusting for patient age.A total of 41,345 pediatric patients were transported by a participating EMS agency to an ED and had complete destination data. A total of 55% of all EMS-transported pediatric patients were transported to a hospital with higher-level pediatric resources. There was variation by site (range = 45%-71%) in the percentage of children who went to a hospital with higher-level pediatric resources. Patients over 15 years of age went to general EDs (57%) more often than younger patients. When stratified by severity, 60% of those with potentially severe illness and 74% of those with potentially severe trauma were transported to a hospital with higher-level pediatric resources.EMS providers commonly transport children to hospitals with higher-level pediatric resources. However, more than one-quarter of children with potentially severe injuries and illnesses are transported to general EDs.

  View details for DOI 10.1111/acem.13641

  View details for PubMedID 30343530

• A Survey of Restraint Methods for the Safe Transport of Children in Ground Ambulances. Pediatric emergency care Woods, R. H., Shah, M., Doughty, C., Gilchrest, A. 2018; 34 (3): 149-153

  Abstract

  The National Highway Traffic Safety Administration (NHTSA) released draft recommendations in 2010 on the safe transport of children in ground ambulances. The purpose of this study was to assess awareness of these guidelines among emergency medical service (EMS) agencies and to identify implementation barriers.We conducted a cross-sectional, anonymous online survey of 911-responding, ground transport EMS agencies in Texas. Demographics, modes of transport based on case scenarios, and barriers to implementation were assessed.Of 62 eligible EMS agencies that took the survey, 35.7% were aware of the NHTSA guidelines, 62.5% agreed they would improve safety, and 41.1% planned to implement them. Seventy-five percent of EMS agencies used the ideal or acceptable alternative to transport children requiring continuous monitoring, and 69.5% chose ideal or acceptable alternatives for children requiring spinal immobilization. The ideal or acceptable alternative was not chosen for children who were not injured or ill (93.2%), ill or injured but not requiring continuous monitoring (53.3%), and situations when multiple patients required transport (57.6%). The main requirements for implementation were provider education, ambulance interior modifications, new guidelines in the EMS agency, and purchase of new equipment.Few EMS agencies are aware of the NHTSA guidelines on safe transport of children in ground ambulances. Although most agencies appropriately transport children who require monitoring, interventions, or spinal immobilization, they use inappropriate means to transport children in situations with multiple patients, lack of injury or illness, or lack of need for monitoring.

  View details for DOI 10.1097/PEC.0000000000001280

  View details for PubMedID 29494459

• Improving Prehospital Protocol Adherence Using Bundled Educational Interventions. Prehospital emergency care Marino, M. C., Ostermayer, D. G., Mondragon, J. A., Camp, E. A., Keating, E. M., Fornage, L. B., Brown, C. A., Shah, M. I. 2018; 22 (3): 361-369

  Abstract

  Seizures and anaphylaxis are life-threatening conditions that require immediate treatment in the prehospital setting. There is variation in treatment of pediatric prehospital patients for both anaphylaxis and seizures. This educational study was done to improve compliance with pediatric prehospital protocols, educate prehospital providers and decrease variation in care.To improve the quality of care for children with seizures and anaphylaxis in the prehospital setting using a bundled, multifaceted educational intervention.Evidence-based pediatric prehospital guidelines for seizures and anaphylaxis were used to create a curriculum for the paramedics in the EMS system. The curriculum included in-person training, videos, distribution of decision support tools, and a targeted social media campaign to reinforce the evidence-based guidelines. Prehospital charts were reviewed for pediatric patients with a chief complaint of anaphylaxis or seizures who were transported by paramedics to one of ten hospitals, including three children's hospitals, for 8 months prior to the intervention and eight months following the intervention. The primary outcome for seizures was whether midazolam was given via the preferred intranasal (IN) or intramuscular (IM) routes. The primary outcome for anaphylaxis was whether IM epinephrine was given.A total of 1,402 pediatric patients were transported for seizures by paramedics to during the study period. A total of 88 patients were actively seizing pre-intervention and 93 post-intervention. Of the actively seizing patients, 52 were given midazolam pre-intervention and 62 were given midazolam post-intervention. Pre-intervention, 29% (15/52) of the seizing patients received midazolam via the preferred IM or IN routes, compared to 74% (46/62) of the seizing patients post-intervention. A total of 45 patients with anaphylaxis were transported by paramedics, 30 pre-intervention and 15 post-intervention. Paramedics administered epinephrine to 17% (5/30) patients pre-intervention and 67% (10/15) patients post-intervention.The use of a bundled, multifaceted educational intervention including in-person training, decision support tools, and social media improved adherence to updated evidence-based pediatric prehospital protocols.

  View details for DOI 10.1080/10903127.2017.1399182

  View details for PubMedID 29364730

• Implementation of a Prehospital Protocol Change For Asthmatic Children PREHOSPITAL EMERGENCY CARE Nassif, A., Ostermayer, D. G., Hoang, K. B., Claiborne, M. K., Camp, E. A., Shah, M. I. 2018; 22 (4): 457–65

  Abstract

  Respiratory distress due to asthma is a common reason for pediatric emergency medical services (EMS) transports. Timely initiation of asthma treatment, including glucocorticoids, improves hospital outcomes. The impact of EMS-administered glucocorticoids on hospital-based outcomes for pediatric asthma patients is unknown.The objective of this study was to evaluate the effect of an evidence-based pediatric EMS asthma protocol update, inclusive of oral glucocorticoid administration, on time to hospital discharge.This was a retrospective cohort study of children (2-18 years) with an acute asthma exacerbation transported by an urban EMS system to 10 emergency departments over 2 years. The investigators implemented an EMS protocol update one year into the study period requiring glucocorticoid administration for all patients, with the major change being inclusion of oral dexamethasone (0.6 mg/kg, max. dose = 10 mg). Protocol implementation included mandatory paramedic training. Data was abstracted from linked prehospital and hospital records. Continuous data were compared before and after the protocol change with the Mann-Whitney test, and categorical data were compared with the Pearson χ2 test.During the study period, 482 asthmatic children met inclusion criteria. After the protocol change, patients were more likely to receive a prehospital glucocorticoid (11% vs. 18%, p = 0.02). Median total hospital time after the protocol change decreased from 6.1 hours (95% CI: 5.4-6.8) to 4.5 hours (95% CI: 4.2-4.8), p < 0.001. Total care time, defined as time from ambulance arrival to hospital discharge, also decreased [6.6 hours (95% CI: 5.8-7.3) vs. 5.2 hours (95% CI: 4.8-5.6), p = 0.01]. Overall, patients were less likely to be admitted to the hospital (30% vs. 21%, p = 0.02) after the change. Those with more severe exacerbations were less likely to be admitted to a critical care unit (82% vs. 44%, p = 0.02) after the change, rather than an acute care floor.Prehospital protocol change for asthmatic children is associated with shorter total hospital and total care times. This protocol change was also associated with decreased hospitalization rates and less need for critical care in those hospitalized. Further study is necessary to determine if other factors also contributed.

  View details for DOI 10.1080/10903127.2017.1408727

  View details for Web of Science ID 000436977600009

  View details for PubMedID 29351496

• Prehospital Providers' Perceptions on Providing Patient and Family Centered Care. Prehospital emergency care Ayub, E. M., Sampayo, E. M., Shah, M. I., Doughty, C. B. 2017; 21 (2): 233-241

  Abstract

  A gap exists in understanding a provider's approach to delivering care that is mutually beneficial to patients, families, and other providers in the prehospital setting. The purpose of this study was to identify attitudes, beliefs, and perceived barriers to providing patient and family centered care (PFCC) in the prehospital setting and to describe potential solutions for improving PFCC during critical pediatric events.We conducted a qualitative, cross-sectional study of a purposive sample of Emergency Medical Technicians (EMTs) and paramedics from an urban, municipal, fire-based EMS system, who participated in the Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPS) course. Two coders reviewed transcriptions of audio recordings from participants' first simulation scenario debriefings and performed constant comparison analysis to identify unifying themes. Themes were verified through member checking with two focus groups of prehospital providers.A total of 122 EMTs and paramedics participated in 16 audiotaped debriefing sessions and two focus groups. Four overarching themes emerged regarding the experience of PFCC by prehospital providers: (1) Perceived barriers included the prehospital environment, limited manpower, multi-tasking medical care, and concern for interference with patient care; (2) Providing emotional support comprised of empathetically comforting caregivers, maintaining a calm demeanor, and empowering families to feel involved; (3) Effective communication strategies consisted of designating a family point person, narration of actions, preempting the next steps, speaking in lay terms, summarizing during downtime, and conveying a positive first impression; (4) Tactics to overcome PFCC barriers were maintaining a line of sight, removing and returning a caregiver to and from the scene, and providing situational awareness.Based on debriefings from simulated scenarios, some prehospital providers identified the provision of emotional support and effective communication as important components to the delivery of PFCC. Other providers revealed several perceived barriers to providing PFCC, though potential solutions to overcome many of these barriers were also identified. These findings can be utilized to integrate effective communication and emotional support techniques into EMS protocols and provider training to overcome perceived barriers to PFCC in the prehospital setting.

  View details for DOI 10.1080/10903127.2016.1241326

  View details for PubMedID 27858502

• Retrospective Review of Pediatric Transport: Where Do Our Patients Go After Transport? Air medical journal Krennerich, E., Sitler, C. G., Shah, M., Lam, F., Graf, J. 2017; 36 (6): 332-338

  Abstract

  This review describes disposition of transported children and identifies contributing factors affecting optimal patient placement. The study describes timing and patient placement indicators in transport patients to identify areas of improvement, re-education, and training.A retrospective chart review for transports via our pediatric specialty transport team from January 1, 2012, to December 31, 2014, was performed. Patients were identified by the transport quality assurance performance improvement database, hospital electronic medical records, and transport medical records.Three thousand two hundred fifty-six pediatric patient transports were reviewed. One hundred forty-three records were excluded. Of the remaining 3,113 patients, admission disposition was: 1,487 (47%) pediatric intensive care unit, 120 (4%) pediatric cardiovascular intensive care unit, 835 (27%) step-down critical care unit, 438 (14%) emergency department, 194 (6%) general floor, 29 (1%) neonatal intensive care unit, and 10 (< 1%) operating room. Of the 22% transported to a lower-acuity unit, several subsequently required critical care. Children transported for traumatic injuries had a shorter emergency department length of stay than medical patients.Our study validates the efficient use of pediatric specialty transport team resources. Many transported patients are critically ill, require specialized pediatric services, or require definitive pediatric emergency department care.

  View details for DOI 10.1016/j.amj.2017.06.006

  View details for PubMedID 29132597

• Prioritising minimum standards of emergency care for children in resource-limited settings. Paediatrics and international child health Glomb, N. W., Shah, M. I., Cruz, A. T. 2017; 37 (2): 116-120

  Abstract

  There is global variation in the ability of hospital-based emergency centres to provide paediatric emergency medicine (PEM) services. Although minimum standards have been proposed, they may not be applicable in resource-limited settings.The goal was to identify reasonable minimum standards to provide safe and effective care for acutely ill children in resource-limited settings.Using previously proposed standards from the International Federation of Emergency Medicine (IFEM), a modified Delphi approach was used to reach agreement regarding minimum standards for PEM in resource-limited settings. Three rounds of surveys were electronically distributed to physicians working in resource-limited settings. Those standards with >67% agreement advanced to the subsequent round.The categories of the surviving criteria included integrated service design, child and family-friendly care, initial assessment of the ill child, stabilising and treating an ill child, staff training and competence, equipment, supplies and medications, quality and safety, child protection, and advanced training and academic research.Experts with experience in acute care of children in resource-limited settings have prioritised standards for paediatric emergency care. They identified 26 variables in nine domains from the original IFEM list of standards and two additional free text standards for the care of acutely ill children. This list may serve as a helpful guide for emergency centres to provide medical treatment for acutely ill children in resource-limited settings.

  View details for DOI 10.1080/20469047.2016.1229848

  View details for PubMedID 27679955

• Resource Document: Coordination of Pediatric Emergency Care in EMS Systems. Prehospital emergency care Remick, K., Gross, T., Adelgais, K., Shah, M. I., Leonard, J. C., Gausche-Hill, M. 2017; 21 (3): 399-407

  Abstract

  Citing numerous pediatric-specific deficiencies within Emergency Medical Services (EMS) systems, the Institute of Medicine (IOM) recommended that EMS systems appoint a pediatric emergency care coordinator (PECC) to provide oversight of EMS activities related to care of children, to promote the integration of pediatric elements into day-to-day services as well as local and/or regional disaster planning, and to promote pediatric education across all levels of EMS providers.A systematic review of the literature was undertaken to describe the evidence for pediatric coordination across the emergency care continuum. The search strategy was developed by the investigators in consultation with a medical librarian and conducted in OVID, Medline, PubMed, Embase, Web of Science, and CINAHL databases from January 1, 1983 to January 1, 2016. All research articles that measured a patient-related or system-related outcome associated with pediatric coordination in the setting of emergency care, trauma, or disaster were included. Opinion articles, commentaries, and letters to the editors were excluded. Three investigators independently screened citations in a hierarchical manner and abstracted data.Of 149 identified titles, nine were included in the systematic review. The nine articles included one interventional study, five surveys, and three consensus documents. All articles favored the presence of pediatric coordination. The interventional study demonstrated improved documentation, clinical management, and staff awareness of high priority pediatric areas.The current literature supports the identification of pediatric coordination to facilitate the optimal care of children within EMS systems. In order for EMS systems to provide high quality care to children, pediatric components must be integrated into all aspects of care including day-to-day operations, policies, protocols, available equipment and medications, quality improvement efforts, and disaster planning. This systematic review and resource document serves as the basis for the National Association of EMS Physicians position statement entitled "Physician Oversight of Pediatric Care in Emergency Medical Systems."

  View details for DOI 10.1080/10903127.2016.1258097

  View details for PubMedID 28059586

• Multicenter Evaluation of Prehospital Opioid Pain Management in Injured Children. Prehospital emergency care Browne, L. R., Shah, M. I., Studnek, J. R., Ostermayer, D. G., Reynolds, S., Guse, C. E., Brousseau, D. C., Lerner, E. B. 2016; 20 (6): 759-767

  Abstract

  The National Association of Emergency Medical Services Physicians' (NAEMSP) Position Statement on Prehospital Pain Management and the joint National Highway Traffic Safety Administration (NHTSA) and Emergency Medical Services for Children (EMSC) Evidence-based Guideline for Prehospital Analgesia in Trauma aim to improve the recognition, assessment, and treatment of prehospital pain. The impact of implementation of these guidelines on pain management in children by emergency medical services (EMS) agencies has not been assessed.Determine the change in frequency of documented pain severity assessment and opiate administration among injured pediatric patients in three EMS agencies after adoption of best practice recommendations.This is a retrospective study of children <18 years of age with a prehospital injury-related primary impression from three EMS agencies. Each agency independently implemented pain protocol changes which included adding the use of age-appropriate pain scales, decreasing the minimum age for opiate administration, and updating fentanyl dosing. We abstracted data from prehospital electronic patient records before and after changes to the pain management protocols. The primary outcomes were the frequency of administration of opioid analgesia and documentation of pain severity assessment as recorded in the prehospital patient care record.A total of 3,597 injured children were transported prior to pain protocol changes and 3,743 children after changes. Opiate administration to eligible patients across study sites regardless of documentation of pain severity was 156/3,089 (5%) before protocol changes and 175/3,509 (5%) after (p = 0.97). Prior to protocol changes, 580 (18%) children had documented pain assessments and 430 (74%) had moderate-to-severe pain. After protocol changes, 644 (18%) patients had pain severity documented with 464 (72%) in moderate-to-severe pain. For all study agencies, pain severity was documented in 13%, 19%, and 22% of patient records both before and after protocol changes. There was a difference in intranasal fentanyl administration rates before (27%) and after (17%) protocol changes (p = 0.02).The proportion of injured children who receive prehospital opioid analgesia remains suboptimal despite implementation of best practice recommendations. Frequency of pain severity assessment of injured children is low. Intranasal fentanyl administration may be an underutilized modality of prehospital opiate administration.

  View details for DOI 10.1080/10903127.2016.1194931

  View details for PubMedID 27411064

• Impact of High-Fidelity Pediatric Simulation on Paramedic Seizure Management. Prehospital emergency care Shah, M. I., Carey, J. M., Rapp, S. E., Masciale, M., Alcanter, W. B., Mondragon, J. A., Camp, E. A., Prater, S. J., Doughty, C. B. 2016; 20 (4): 499-507

  Abstract

  A simulation-based course, Pediatric Simulation Training for Emergency Prehospital Providers (PediSTEPPs), was developed to optimize pediatric prehospital care. Seizures are common in Emergency Medical Services (EMS), and no studies have evaluated pediatric outcomes after EMS simulation training.The primary objective was to determine if PediSTEPPs enhances seizure protocol adherence in blood glucose measurement and midazolam administration for seizing children. The secondary objective was to describe management of seizing patients by EMS and Emergency Departments (EDs).This is a two-year retrospective cohort study of paramedics who transported 0-18 year old seizing patients to ten urban EDs. Management was compared between EMS crews with at least one paramedic who attended PediSTEPPs and crews that had none. Blood glucose measurement, medications administered, intravenous (IV) access, seizure recurrence, and respiratory failure data were collected from databases and run reports. Data were compared using Pearson's χ(2) test and odds ratios with 95% confidence intervals (categorical) and the Mann-Whitney test (continuous).Of 2200 pediatric transports with a complaint of seizure, 250 (11%) were actively seizing at the time of transport. Of these, 65 (26%) were treated by a PediSTEPPs-trained paramedic. Blood glucose was slightly more likely to be checked by trained than untrained paramedics (OR = 1.35, 95% CI 0.72-2.51). Overall, 58% received an indicated dose of midazolam, and this was slightly more likely in the trained than untrained paramedics (OR = 1.39, 95% CI 0.77-2.49). There were no differences in secondary outcomes between groups. The prevalence of hypoglycemia was low (2%). Peripheral IVs were attempted in 80%, and midazolam was predominantly given by IV (68%) and rectal (12%) routes, with 51% receiving a correct dose. Seizures recurred in 22%, with 34% seizing on ED arrival. Respiratory failure occurred in the prehospital setting in 25 (10%) patients in the study.Simulation-based training on pediatric seizure management may have utility. Data support the need to optimize the route and dose of midazolam for seizing children. Blood glucose measurement in seizure protocols may warrant reprioritization due to low hypoglycemia prevalence.seizure; emergency medical services; simulation; pediatrics.

  View details for DOI 10.3109/10903127.2016.1139217

  View details for PubMedID 26953677

• Continuing Medical Education for Air Medical Providers: The Successes and Challenges. Pediatric emergency care Miller, J. O., Thammasitboon, S., Hsu, D. C., Shah, M. I., Minard, C. G., Graf, J. M. 2016; 32 (2): 87-92

  Abstract

  Research has shown that patients transported by nonpediatric teams have higher rates of morbidity and mortality. There is currently a paucity of pediatric standardized ongoing medical education for emergency medical service providers, thus we aimed to develop a model curriculum to increase their knowledge regarding pediatric respiratory distress and failure.The curriculum was based on the Kolb Learning Cycle to optimize learning. Target learners were flight nurses (registered nurse) and emergency medical technicians of a private helicopter emergency transport team. The topics included were pediatric stridor, wheezing, and respiratory failure. Online modules were developed for continued spaced education. Knowledge gained from the interventions was measured by precurricular and postcurricular testing and compared with paired t tests. A linear mixed regression model was used to investigate covariates of interest.Sixty-two learners attended the workshop. Fifty-nine learners completed both precurricular and postcurricular testing. The mean increase between pretest and posttest scores was 12.1% (95% confidence interval, 9.4, 14.8; P < 0.001). Type of licensure (private emergency medical technician vs registered nurse) and number of years experience had no association with the level of knowledge gained. Learners who had greater than 1 year of pediatric transport experience scored higher on their pretests. There was no significant retention shown by those who participated in spaced education.The curriculum was associated with a short term increased knowledge regarding pediatric respiratory distress and failure for emergency helicopter transport providers and could be used as an alternative model to develop standardized ongoing medical education in pediatrics. Further work is needed to achieve knowledge retention in this learner population.

  View details for DOI 10.1097/PEC.0000000000000416

  View details for PubMedID 26841111

• 2015 Pediatric Research Priorities in Prehospital Care. Prehospital emergency care Browne, L. R., Shah, M. I., Studnek, J. R., Farrell, B. M., Mattrisch, L. M., Reynolds, S., Ostermayer, D. G., Brousseau, D. C., Lerner, E. B. 2016; 20 (3): 311-6

  Abstract

  Pediatric prehospital research has been limited, but work in this area is starting to increase particularly with the growth of pediatric-specific research endeavors. Given the increased interest in pediatric prehospital research, there is a need to identify specific research priorities that incorporate the perspective of prehospital providers and other emergency medical services (EMS) stakeholders.To develop a list of specific research priorities that is relevant, specific, and important to the practice of pediatric prehospital care.Three independent committees of EMS providers and researchers were recruited. Each committee developed a list of research topics. These topics were collated and used to initiate a modified Delphi process for developing consensus on a list of research priorities. Participants were the committee members. Topics approved by 80% were retained as research priorities. Topics that were rejected by more than 50% were eliminated. The remaining topics were modified and included on subsequent surveys. Each survey allowed respondents to add additional topics. The surveys were continued until all topics were either successfully retained or rejected and no new topics were suggested.Fifty topics were identified by the three independent committees. These topics were included on the initial electronic survey. There were 5 subsequent surveys. At the completion of the final survey a total of 29 research priorities were identified. These research priorities covered the following study areas: airway management, asthma, cardiac arrest, pain, patient-family interaction, resource utilization, seizure, sepsis, spinal immobilization, toxicology, trauma, training and competency, and vascular access. The research priorities were very specific. For example, under airway the priorities were: "identify the optimal device for effectively managing the airway in the prehospital setting" and "identify the optimal airway management device for specific disease processes."This project developed a list of relevant, specific, and important research priorities for pediatric prehospital care. Some similarities exist between this project and prior research agendas but this list represents a current, more specific research agenda and reflects the opinions of working EMS providers, researchers, and leaders.emergency medical technician; research; emergency medical services; priorities.

  View details for DOI 10.3109/10903127.2015.1102997

  View details for PubMedID 26808233

• Prehospital Opioid Administration in the Emergency Care of Injured Children. Prehospital emergency care Browne, L. R., Studnek, J. R., Shah, M. I., Brousseau, D. C., Guse, C. E., Lerner, E. B. 2016; 20 (1): 59-65

  Abstract

  Prior studies have identified provider and system characteristics that impede pain management in children, but no studies have investigated the effect of changing these characteristics on prehospital opioid analgesia. Our objectives were to determine: 1) the frequency of opioid analgesia and pain score documentation among prehospital pediatric patients after system wide changes to improve pain treatment, and 2) if older age, longer transport times, the presence of vascular access and pain score documentation were associated with increased prehospital administration of opioid analgesia in children.This was a retrospective cross-sectional study of pediatric patients aged 3-18 years assessed by a single EMS system between October 1, 2011 and September 30, 2013. Prior to October 2011, the EMS system had implemented 3 changes to improve pain treatment: (1) training on age appropriate pain scales, (2) protocol changes to allow opioid analgesia without contacting medical control, and (3) the introduction of intranasal fentanyl. All patients with working assessments of blunt, penetrating, lacerating, and/or burn trauma were included. We used descriptive statistics to determine the frequency of pain score documentation and opioid analgesia administration and logistic regression to determine the association of age, transport time, and the presence of intravenous access with opioid analgesia administration.Of the 1,368 eligible children, 336 (25%) had a documented pain score. Eleven percent (130/1204) of children without documented contraindications to opioid administration received opioids. Of the children with no documented pain score and no protocol exclusions, 9% (81/929) received opioid analgesia, whereas 18% (49/275) with a documented pain score ≥4 and no protocol exclusions received opioids. Multivariate analysis revealed that vascular access (OR = 11.89; 95% CI: 7.33-19.29), longer patient transport time (OR = 1.07; 95% CI: 1.04-1.11), age (OR 0.93; 95% CI: 0.88-0.98) and pain score documentation (OR 2.23; 95% CI: 1.40-3.55) were associated with opioid analgesia.Despite implementation of several best practice recommendations to improve prehospital pain treatment, few children have a documented pain score and even fewer receive opioid analgesia. Children with longer transport times, successful IV placement, and/or documentation of pain score(s) were more likely to receive prehospital analgesia.

  View details for DOI 10.3109/10903127.2015.1056897

  View details for PubMedID 26727339

• A consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation. The journal of trauma and acute care surgery Lerner, E. B., Drendel, A. L., Falcone, R. A., Weitze, K. C., Badawy, M. K., Cooper, A., Cushman, J. T., Drayna, P. C., Gourlay, D. M., Gray, M. P., Shah, M. I., Shah, M. N. 2015; 78 (3): 634-8

  Abstract

  Verbal prehospital reports on an injured patient’s condition are typically used by trauma centers to determine if a trauma team should be present in the emergency department prior to patient arrival (i.e., trauma team activation). Efficacy studies of trauma team activation protocols cannot be conducted without a criterion standard definition for which pediatric patients need a trauma team activation.To develop a consensus-based criterion standard definition for pediatric patients who needed the highest-level trauma team activation.Ten local and national experts in emergency medicine, emergency medical services, and trauma were recruited to participate in a Modified Delphi survey process. The initial survey was populated based on outcomes that had been used in previously published literature on trauma team activation. The criterion standard definition for trauma team activation was refined iteratively based on survey responses until at least 80% agreement was achieved for each criterion.After five voting rounds a consensus-based definition for pediatric trauma team activation was developed. Twelve criteria were identified along with a corresponding time interval in which each criterion had to occur. The criteria include receiving specific surgery types, interventional radiology, advanced airway management, thoracostomy, blood products, spinal injury, emergency cesarean section, vasopressors, burr hole or other procedure to relieve intracranial pressure, pericardiocentesis, thoracotomy, and death in the emergency department. All expert panel members voted in all 5 voting rounds, except 1 member missed rounds 1 and 2. Each criterion had greater than 80% agreement from the panel.A criterion standard definition for the highest-level pediatric trauma team activation was developed. This criterion standard definition will advance trauma research by allowing investigators to determine the accuracy and effectiveness of highest-level pediatric trauma team activation protocols.Qualitative

  View details for DOI 10.1097/TA.0000000000000543

  View details for PubMedID 25710438

  View details for PubMedCentralID PMC4341956

• An Evidence-based Guideline for Pediatric Prehospital Seizure Management Using GRADE Methodology. Prehospital emergency care Shah, M. I., Macias, C. G., Dayan, P. S., Weik, T. S., Brown, K. M., Fuchs, S. M., Fallat, M. E., Wright, J. L., Lang, E. S. 2014; 18 Suppl 1: 15-24

  Abstract

  The objective of this guideline is to recommend evidence-based practices for timely prehospital pediatric seizure cessation while avoiding respiratory depression and seizure recurrence.A multidisciplinary panel was chosen based on expertise in pediatric emergency medicine, prehospital medicine, and/or evidence-based guideline development. The panel followed the National Prehospital EBG Model using the GRADE methodology to formulate questions, retrieve evidence, appraise the evidence, and formulate recommendations. The panel members initially searched the literature in 2009 and updated their searches in 2012. The panel finalized a draft of a patient care algorithm in 2012 that was presented to stakeholder organizations to gather feedback for necessary revisions.Five strong and ten weak recommendations emerged from the process; all but one was supported by low or very low quality evidence. The panel sought to ensure that the recommendations promoted timely seizure cessation while avoiding respiratory depression and seizure recurrence. The panel recommended that all patients in an active seizure have capillary blood glucose checked and be treated with intravenous (IV) dextrose or intramuscular (IM) glucagon if <60 mg/dL (3 mmol/L). The panel also recommended that non-IV routes (buccal, IM, or intranasal) of benzodiazepines (0.2 mg/kg) be used as first-line therapy for status epilepticus, rather than the rectal route.Using GRADE methodology, we have developed a pediatric seizure guideline that emphasizes the role of capillary blood glucometry and the use of buccal, IM, or intranasal benzodiazepines over IV or rectal routes. Future research is needed to compare the effectiveness and safety of these medication routes.

  View details for DOI 10.3109/10903127.2013.844874

  View details for PubMedID 24298939

• The development of evidence-based prehospital guidelines using a GRADE-based methodology. Prehospital emergency care Brown, K. M., Macias, C. G., Dayan, P. S., Shah, M. I., Weik, T. S., Wright, J. L., Lang, E. S. 2014; 18 Suppl 1: 3-14

  Abstract

  The burgeoning literature in prehospital care creates an opportunity to improve care through evidence-based guidelines (EBGs). Previously, an established process for the creation of such guidelines and adoption and implementation at the local level was lacking. This has led to great variability in the content of prehospital protocols in different jurisdictions across the globe. Recently the Federal Interagency Committee on Emergency Medical Services (FICEMS) and the National EMS Advisory Council (NEMSAC) approved a National Prehospital Evidence-based Guideline Model Process for the development, implementation, and evaluation of EBGs. The Model Process recommends the use of established guideline development tools such as Grading of Recommendations, Assessment, Development, and Evaluation (GRADE). Objective. To describe the process of development of three prehospital EBGs using the National Prehospital EBG Model Process (EBG Model Process) and the GRADE EBG development tool.We conducted three unique iterations of the EBG Model Process utilizing the GRADE EBG development tool. The process involved 6 distinct and essential steps, including 1) assembling the expert panel and providing GRADE training; 2) defining the evidence-based guideline (EBG) content area and establishing the specific clinical questions to address in patient, intervention, comparison, and outcome (PICO) format; 3) prioritizing outcomes to facilitate systematic literature searches; 4) creating GRADE tables, or evidence profiles, for each PICO question; 5) vetting and endorsing GRADE evidence tables and drafting recommendations; and 6) synthesizing recommendations into an EMS protocol and visual algorithm. Feedback and suggestions for improvement were solicited from participants and relevant stakeholders in the process.We successfully used the process to create three separate prehospital evidence-based guidelines, formatted into decision tree algorithms with levels of evidence and graded recommendations assigned to each decision point. However, the process revealed itself to be resource intensive, and most of the suggestions for improvement would require even more resource utilization.The National Prehospital EBG Model Process can be used to create credible, transparent, and usable prehospital evidence-based guidelines. We suggest that a centralized or regionalized approach be used to create and maintain a full set of prehospital EBGs as a means of optimizing resource use.

  View details for DOI 10.3109/10903127.2013.844871

  View details for PubMedID 24279739

• Equipment for ground ambulances. Prehospital emergency care 2014; 18 (1): 92-7

  View details for DOI 10.3109/10903127.2013.851312

  View details for PubMedID 24168014

• Pediatric Prehospital Seizure Management CLINICAL PEDIATRIC EMERGENCY MEDICINE Carey, J. M., Shah, M. I. 2014; 15 (1): 59-66

  View details for DOI 10.1016/j.cpem.2014.01.006

  View details for Web of Science ID 000219594100008

• EMSC program manager survey on education of prehospital providers. Prehospital emergency care Ngo, T. L., Belli, K., Shah, M. I. 2014; 18 (3): 424-8

  Abstract

  Although pediatric-specific objectives for the initial education of prehospital providers have been established, uniform implementation of these objectives and guidelines for hours of required pediatric continuing education (CE) for prehospital providers have not been established.To examine the content and number of hours of pediatric-specific education that prehospital providers receive during initial certification and recertification. Second, to identify barriers to implementing specific requirements for pediatric education of prehospital providers.Electronic surveys were sent to 55 EMS for Children (EMSC) State Partnership grantee program managers inquiring about the certification and recertification processes of prehospital providers and barriers to receiving pediatric training in each jurisdiction.We had a 91% response rate for our survey. Specified pediatric education hours exist in more states and territories for recertification (63-67%) than initial certification (41%). Limitations in funding, time, instructors, and accessibility are barriers to enhancing pediatric education.Modifying statewide policies on prehospital education and increasing hands-on training may overcome identified barriers.

  View details for DOI 10.3109/10903127.2013.869641

  View details for PubMedID 24548019

• Prospective pilot derivation of a decision tool for children at low risk for testicular torsion. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Shah, M. I., Chantal Caviness, A., Mendez, D. R. 2013; 20 (3): 271-8

  Abstract

  The purpose of this study was to derive a pilot clinical decision tool with 100% negative predictive value for testicular torsion based on prospectively collected data in children with acute scrotal pain.This was a prospective cohort study of a convenience sample of newborn to 21-year-old males evaluated for acute (72 hours or less) scrotal pain at an urban children's hospital emergency department (ED). A pediatric emergency medicine fellow or attending physician documented history and examination findings on a standardized data collection form. The study investigators used ultrasound (US), operative reports, or clinical follow-up to identify patients who had testicular torsion. Pearson's chi-square test and odds ratios (OR) were used to identify factors associated with the diagnosis of testicular torsion. The authors also used a recursive partitioning model to create a low-risk decision tool for testicular torsion.Of the 450 eligible patients, 228 (51%) were enrolled, with a mean (± SD) age of 9.9 (± 4.1) years, including 21 (9.2%, 95% confidence interval [CI] = 5.8% to 13.7%) with testicular torsion. The derived clinical decision tool consisted of three variables: horizontal or inguinal testicular lie (OR = 18.17, 95% CI = 6.2 to 53.2), nausea or vomiting (OR = 5.63, 95% CI = 2.08 to 15.22), and age 11 to 21 years (OR = 3.9, 95% CI = 1.27 to 11.97). These variables had a sensitivity of 100% (95% CI = 98% to 100%) and negative predictive value of 100% (95% CI = 98% to 100%) for the diagnosis of testicular torsion.Based on a decision tool derived with recursive partitioning, study patients with all of the following characteristics had no risk of testicular torsion: normal testicular lie, lack of nausea or vomiting, and age 0 to 10 years. Future research should focus on externally validating this tool to optimize emergent evaluation when testicular torsion is likely, while minimizing routine sonographic evaluation when patients are unlikely to have a serious condition requiring immediate management.

  View details for DOI 10.1111/acem.12086

  View details for PubMedID 23517259

• Prehospital Management of Pediatric Trauma CLINICAL PEDIATRIC EMERGENCY MEDICINE Shah, M. I. 2010; 11 (1): 10-17

  View details for DOI 10.1016/j.cpem.2009.12.003

  View details for Web of Science ID 000219559000003

• Cardiac troponin increases among runners in the Boston Marathon ANNALS OF EMERGENCY MEDICINE Fortescue, E. B., Shin, A. Y., Greenes, D. S., Mannix, R. C., Agarwal, S., Feldman, B. J., Shah, M. I., Rifai, N., Landzberg, M. J., Newburger, J. W., Almond, C. S. 2007; 49 (2): 137-143

  Abstract

  Studies indicate that running a marathon can be associated with increases in serum cardiac troponin levels. The clinical significance of such increases remains unclear. We seek to determine the prevalence of troponin increases and epidemiologic factors associated with these increases in a large and heterogeneous cohort of marathon finishers.Entrants in the 2002 Boston Marathon were recruited 1 to 2 days before the race. Data collected included demographic and training history, symptoms experienced during the run, and postrace troponin T and I levels. Simple descriptive statistics were performed to describe the prevalence of troponin increases and runner characteristics.Of 766 runners enrolled, 482 had blood analyzed at the finish line. In all, 34% were women, 20% were younger than 30 years, and 92% had run at least 1 previous marathon. Most runners (68%) had some degree of postrace troponin increase (troponin T > or = 0.01 ng/mL or troponin I > or = 0.1 ng/mL), and 55 (11%) had significant increases (troponin T > or = 0.075 ng/mL or troponin I > or = 0.5 ng/mL). Running inexperience (< 5 previous marathons) and young age (< 30 years) were associated with elevated troponins. These correlates were robust throughout a wide range of troponin thresholds considered. Health factors, family history, training, race performance, and symptoms were not associated with increases.Troponin increases were relatively common among marathon finishers and can reach levels typically diagnostic for acute myocardial infarction. Less marathon experience and younger age appeared to be associated with troponin increases, whereas race duration and the presence of traditional cardiovascular risk factors were not. Further work is needed to determine the clinical significance of these findings.

  View details for DOI 10.1016/j.annemergmed.2006.09.024

  View details for Web of Science ID 000243957800002

  View details for PubMedID 17145114