Background In the prehospital setting, endotracheal intubation (ETI) may be required to secure the coronavirus disease 2019 (COVID-19) patient airway. It has been suggested that the use of a protective barrier can reduce possible aerosol delivery from patients to clinicians during ETI. We sought to assess the performance of ETI by paramedics wearing personal protective equipment with and without the use of a box barrier. Methods A randomized, crossover simulation study was performed in a simulation laboratory. Study participants were 18 paramedics actively working in the clinical environment. Participants’ performance of ETI via direct laryngoscopy (DL) with and without the use of a box barrier was assessed. The sequence of intubation was randomized to either BoxDL-first or DL-first. The primary outcome was the success rate of ETI on first-attempt. The secondary and tertiary outcomes were ETI success rates on three attempts and total intubation time, respectively. Results There were no differences between the DL group and the BoxDL group in one-attempt success rates (14/18 vs 12/18; P = 0.754), and in overall success rates (16/18 vs 14/18; P = 0.682). The mean (standard deviation) of the total intubation times for the DL group and the BoxDL group were 27.3 (19.7) seconds and 36.8 (26.2) seconds, respectively (P < 0.015). Conclusions The findings of this pilot study suggest that paramedics wearing personal protective equipment can successfully perform ETI using a barrier box, but the intubation time may be prolonged. The applicability of these findings to the care of COVID-19 patients remain to be investigated.

Transient synovitis (TS) is a self-limiting disease characterized clinically by acute hip pain. The diagnosis is confirmed by excluding other severe diseases, such as septic arthritis, osteomyelitis, and Legg-Calvé-Perthes disease. Ultrasonography examination frequently reveals hip effusion. 1,2 A point-of-care ultrasonography (POCUS) decision-support algorithm (DSA) is regularly used to identify TS in the pediatric emergency department (ED) of Rambam Health Care Campus, a tertiary hospital in Haifa, Israel. 2,3 The POCUS-DSA includes a set of 5 clinical criteria that must be met, followed by bedside ultrasonography examination of the hip joint (Figure ). 1,2 Here, we evaluate the performance of the POCUS-DSA in the diagnosis of TS among children presenting to the pediatric ED. MethodsThis study was approved by the Rambam Health Care Campus ethics committee. Informed consent was not necessary because of the retrospective nature of the study, in accordance with Rambam Health Care Campus policy. The reporting guideline for case series was used for this study. This case series analyzed all children with nontraumatic hip tenderness who met the POCUS-DSA criteria between January 1, 2014, and December 31, 2019. Ultrasonography was performed using an accepted technique. 2 Patients with hip effusion received a diagnosis of TS in the ED and were scheduled for a follow-up visit in 5 to 7 days. Patients without hip effusion were assessed with laboratory or imaging tests, as per clinician judgment (Figure). 2 A final diagnosis of TS was made for any patient who had spontaneous resolution of symptoms and a reduction in the amount of effusion at the follow-up visit. 1 Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), positive likelihood ratio (LR), and negative LR were used to assess Author affiliations and article information are listed at the end of this article.

Summary Statement Shortage of personal protective equipment (PPE) for frontline healthcare workers managing the current severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic is a major, global challenge. In this pilot study, we describe a simulation-based method for evaluating the suitability and acceptability of an alternative biological isolation garment (BIG, a gown or a suit) for clinical use by emergency department (ED) personnel. Using a high-fidelity simulator, participants provided airway management according to the SARS-CoV-2 protocol. A nonvisible fluorescent marker was used as a surrogate marker of contamination. We assessed ultraviolet light visualization of the fluorescent marker after doffing and satisfaction with donning, use during simulation, and doffing. We found that after doffing, markers were not visualized on any of the participants and that the median satisfaction scores of the alternative and standard BIG (sBIG) were 4 [interquartile range (IQR) = 1–5] and 4 (IQR = 2–4), respectively. The results suggest the suitability and acceptability of the alternative BIG (aBIG) for use by ED personnel.

Background: Cast immobilization is the primary treatment for children with forearm fractures. After emergency department (ED) discharge, some patients develop cast-related pain (CstRP) around the distal part of the upper extremity. We examined variables associated with ED revisits due to CstRP in children with forearm fractures. Methods: A retrospective cohort study of all children who were treated with cast immobilization for forearm fracture over a 7-year period was conducted. Patient demographics, fracture location, casting method (below elbow/above elbow), first visit pain scores, treatment with fracture reduction, and revisit data were collected. Multivariate regression was used to identify predictors of revisits due to CstRP within 72 hrs post-discharge. Results: A total of 2307 children were treated with cast immobilization; 95 (4.2%) revisited the ED due to CstRP (median pain score 7, interquartile range 5-9). No patient had neurovascular compromise or required surgery or re-reduction. Fifty-eight (61.1%) patients were treated with cast splitting, 10 (10.5%) with trimming, and 27 (28.4%) with cast replacement. Variables on first visit that were associated with increased odds for ED revisit included treatment with fracture reduction (odds ratio [OR] 2.31; 95% confidence interval [CI] 1.58-3.36) and a median pain score of 6 or more upon ED presentation (OR 1.57; 95% CI 1.32-2.13). Discussion: A small number of children with forearm fractures revisited the ED due to CstRP. Study findings suggest that being treated with closed reduction and having a pain score ≥ 6 on the first visit were associated with ED revisit due to CstRP.

Sixty-minute postinjection depot triptorelin levels of LH can be successfully used to evaluate the efficacy of treatment with this agent. Limits for suppressed levels have been determined.