No abstract

Among infants with bronchiolitis treated in the emergency department, combined therapy with dexamethasone and epinephrine may significantly reduce hospital admissions. (Current Controlled Trials number, ISRCTN56745572.)

For the treatment of acute traumatic musculoskeletal injuries, ibuprofen provides the best analgesia among the 3 study medications.

Children treated with removable splinting have better physical functioning and less difficulty with activities than those treated with a cast.

Triage nurse initiation of oral corticosteroid before physician assessment was associated with reduced times to clinical improvement and discharge, and reduced admission rates in children presenting with moderate to severe acute asthma exacerbations.

No abstract

Objectives: Minor head trauma accounts for a significant proportion of pediatric emergency department (ED) visits. In children younger than 24 months, scalp hematomas are thought to be associated with the presence of intracranial injury (ICI). We investigated which scalp hematoma characteristics were associated with increased odds of ICI in children less than 17 years who presented to the ED following minor head injury and whether an underlying linear skull fracture may explain this relationship.Methods: This was a secondary analysis of 3,866 patients enrolled in the Canadian Assessment of Tomography of Childhood Head Injury (CATCH) study. Information about scalp hematoma presence (yes/no), location (frontal, temporal/parietal, occipital), and size (small and localized, large and boggy) was collected by emergency physicians using a structured data collection form. ICI was defined as the presence of an acute brain lesion on computed tomography. Logistic regression analyses were adjusted for age, sex, dangerous injury mechanism, irritability on examination, suspected open or depressed skull fracture, and clinical signs of basal skull fracture.Results: ICI was present in 159 (4.1%) patients. The presence of a scalp hematoma (n = 1,189) in any location was associated with significantly greater odds of ICI (odds ratio [OR] = 4.4, 95% confidence interval [CI] = 3.06 to 6.02), particularly for those located in temporal/parietal (OR = 6.0, 95% CI = 3.9 to 9.3) and occipital regions (OR = 5.6, 95% CI = 3.5 to 8.9). Both small and localized and large and boggy hematomas were significantly associated with ICI, although larger hematomas conferred larger odds (OR = 9.9, 95% CI = 6.3 to 15.5). Although the presence of a scalp hematoma was associated with greater odds of ICI in all age groups, odds were greatest in children aged 0 to 6 months (OR = 13.5, 95% CI = 1.5 to 119.3). Linear skull fractures were present in 156 (4.0%) patients. Of the 111 patients with scalp hematoma and ICI, 57 (51%) patients had a linear skull fracture and 54 (49%) did not. The association between scalp hematoma and ICI attenuated but remained significant after excluding patients with linear skull fracture (OR = 3.3, 95% CI = 2.1 to 5.1).

R adial-head subluxation is a common arm injury among young children and often results in a visit to the emergency department.1 This type of injury occurs when forceful longitudinal traction is applied to an extended and pronated forearm.2 Radial-head subluxation is easily recognized by its clinical presentation and can be treated by a simple reduction technique involving hyperpronation or supination and flexion of the injured arm. [3][4][5][6][7] Despite the ease of diagnosis and treatment, children with radial-head subluxation often wait hours in the emergency department for a reduction that takes minutes to perform. 8 These visits have direct health care costs and involve time and stress for the child and their family. Early treatment and shorter wait times correlate with patient satisfaction.9,10 Patient satisfaction is comparable when minor injuries are cared for by a nurse instead of by a physician.11-13 Nurse-initiated treatments are increasingly a focus of health care. 14-17Treatment of radial-head subluxation is an appropriate area to consider nurse-initiated care. Our objective was to determine whether triage nurses, trained in the recognition and treatment of radial-head subluxation, could successfully reduce radial-head subluxation at a rate similar to that of physicians. Methods Study designWe performed an open (i.e., unblinded) noninferiority, cluster-randomized control trial to assess whether triage nurses in the emergency department could, using a medical directive (Appendix 1, available at www .cmaj .ca /lookup /suppl /doi :10 .1503 /cmaj.131101/-/DC1), achieve rates of successful reduction of radial-head subluxation that were not substantially lower than those of physicians. Research CMAJ Background: Radial-head subluxation is an easily identified and treated injury. We investigated whether triage nurses in the emergency department can safely reduce radial-head subluxation at rates that are not substantially lower than those of emergency department physicians. Methods:We performed an open, noninferiority, cluster-randomized control trial. Children aged 6 years and younger who presented to the emergency department with a presentation consistent with radial-head subluxation and who had sustained a known injury in the previous 12 hours were assigned to either nurse-initiated or physician-initiated treatment, depending on the day. The primary outcome was the proportion of children who had a successful reduction (return to normal arm usage). We used a noninferiority margin of 10%. Results:In total, 268 children were eligible for inclusion and 245 were included in the final analysis. Of the children assigned to receive physician-initiated care, 96.7% (117/121) had a successful reduction performed by a physician. Of the children assigned to receive nurse-treatment care, 84.7% (105/124) had a successful reduction performed by a nurse. The difference in the proportion of successful radial head subluxations between the groups was 12.0% (95% confidence interval [CI] 4.8% to 19.7%). Noninferiority of nurs...