BackgroundVaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visits and admission in children with sickle cell disease (SCD).ObjectivesThis study aims to evaluate whether the use of a new pain management pathway using intranasal (IN) fentanyl from triage leads to improved care, translated by a decrease in time to first opiate dose.MethodsWe performed a retrospective chart review of patients with SCD who presented to the emergency department (ED) with VOC, in the period pre- (52 patients) and post- (44 patients) implementation period of the protocol. Time to first opiate was the primary outcome and was evaluated pre- and postimplementation. Patients received a first opiate dose within 52.3 minutes of registration (interquantile range [IQR] 30.6, 74.6), corresponding to a 41.4-minute reduction in the opiate administration time (95% confidence interval [CI] -56.1, -27.9). There was also a 43% increase in the number of patients treated with a nonintravenous (IV) opiate as first opiate dose (95% CI 26, 57). In patients who were discharged from the ED, there was a 49% decrease in the number of IV line insertions (95% CI -67, -22). There was no difference in the hospitalization rates (difference of 6 [95% CI -13, 25]).ConclusionsThis study validates the use of our protocol using IN fentanyl as first treatment of VOC in the ED by significantly reducing the time to first opiate dose and the number of IVs.

Background Vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visit and admission in children with sickle cell disease (SCD). Objectives This study aimed to evaluate whether the implementation of a protocol promoting the use of oral morphine as a primary intervention has led to improved care of SCD. Methods We performed a retrospective chart review of patients with SCD who presented to the emergency department (ED) and hematology outpatient clinic (HOC) with VOC, in the year pre and postimplementation of the protocol. The primary outcome was the hospitalization rate. Results The protocol resulted in a significant 43% reduction of hospitalization rate (95% confidence interval [CI] -53.0, 26.5). Results also showed a 35% increase in the use of oral morphine as first-line opiate treatment (95% CI 17.9, 45.2), a 28% increase in the use of pain scales (95% CI 17.3, 43.2) and a 30% net increase in patients eventually not requiring intravenous (IV) line placement (95% CI 16.0, 39.9). While we did observe an overall decrease in length of stay in ED of -55 min (95% CI -100.6, -12.0), there was a nonsignificant decrease of 7 minutes (95% CI -26, 3) in the opiate administration time. Conclusions This study validates the use of our oral morphine protocol for the treatment of VOC by significantly reducing the admission rate and decreasing the number of IVs.

More children and adolescents are participating in competitive sports than ever before, causing an overall increase in sport-related injuries. Concussion is a common injury in the pediatric population and its prevalence has increased with increased visibility and awareness. This chapter will discuss the clinical presentation, evaluation, and management of concussions sustained by pediatric athletes, while addressing the distinctive factors that pertain to this population. Management of concussion should be tailored to patients' symptoms and should focus on an early and gradual return to both cognitive and noncontact low-risk physical activity. A multidisciplinary approach is often helpful in addressing more specific symptoms, which fall into the somatic, cognitive, vestibular, emotional, and sleep domains. A prolonged recovery is defined by symptoms lasting more than 4 weeks. Individualized return-to-play decisions should focus on the safety of the young athlete.

BACKGROUND: Sickle cell vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visit and admission in children with this condition. Intranasal (IN) fentanyl has been used increasingly for pain treatment in the emergency department (ED), including for patient with sickle cell disease (SCD). OBJECTIVES: We aim to evaluate whether the use of a new pain management pathway using IN fentanyl from triage as first line therapy for patient with SCD in VOC will lead to improved care of SCD, translated by a decrease in time to first opiate dose, aiming to meet quality of care indicators. We also aim to prospectively evaluate patient and parent satisfaction with the use of IN Fentanyl. DESIGN/METHODS: Retrospective chart review of patients with SCD who presented to the ED with VOC, in the period pre (Jan - June 2014) and post (Oct - June 2016) implementation of the protocol. Patients in pre received oral or intravenous (IV) opiates as per previous management pathway. Patients in post received IN fentanyl if their pain was moderate-to-severe. Time to first opiate was evaluated pre and post implementation. Patient and parent satisfaction questionnaires were filled prospectively if patient presented during research nurse working hours, and median scores were calculated. RESULTS: Over the two periods, a total of 107 ED patients (56 pre, 51 post) were included respectively, and 14/51 patients filled out the satisfaction questionnaire. There was a significant difference of -45.8 min (95% CI -61.1, -31.9) in the opiate administration time, now meeting quality of care indicators. There was a significant increase of 45.7% (95% CI 29.0, 59.0) in the use of pain scales at triage evaluation. There was an increase in the number of patient treated with a non-IV opiate as 1st opiate dose: a difference of 43.8% (95% CI 26.7, 57.4). There was no difference in the number of patients without IV treatment: a difference of 15.8 (95% CI -1.4, 32.1). There was no difference in the hospitalization rates: a difference of 12.6 (95% CI -6.2, 30.1. Patient and parent satisfaction with IN treatment was 3.5/5 and 2/5 for the 14 patients evaluated prospectively. CONCLUSION: This study validates the use of our protocol using IN fentanyl for the treatment of VOC in the ED by significantly reducing the time to 1st opiate dose. However, our protocol did not decrease the number of IVs.

Purpose Complex clinical situations, involving multiple medical specialists, create potential for tension or lack of clarity over leadership roles and may result in miscommunication, errors and poor patient outcomes. Even though copresence has been shown to overcome some differences among team members, the coordination literature provides little guidance on the relationship between coordination and leadership in highly specialized health settings. The purpose of this paper is to determine how different specialties involved in critical medical situations perceive the role of a leader and its contribution to effective crisis management, to better define leadership and improve interdisciplinary leadership and education. Design/methodology/approach A qualitative study was conducted featuring purposively sampled, semi-structured interviews with 27 physicians, from three different specialties involved in crisis resource management in pediatric centers across Canada: Pediatric Emergency Medicine, Otolaryngology and Anesthesia. A total of three researchers independently organized participant responses into categories. The categories were further refined into conceptual themes through iterative negotiation among the researchers. Findings Relatively "structured" (predictable) cases were amenable to concrete distributed leadership - the performance by micro-teams of specialized tasks with relative independence from each other. In contrast, relatively "unstructured" (unpredictable) cases required higher-level coordinative leadership - the overall management of the context and allocations of priorities by a designated individual. Originality/value Crisis medicine relies on designated leadership over highly differentiated personnel and unpredictable events. This challenges the notion of organic coordination and upholds the validity of a concept of leadership for crisis medicine that is not reducible to simple coordination. The intersection of predictability of cases with types of leadership can be incorporated into medical simulation training to develop non-technical skills crisis management and adaptive leaderships skills.

relationships between demographics, initial presentation measures, and one-month follow-up QOL and MDF. Variables significant in univariable analyses (p<0.05) were included in multivariable regression models. RESULTS: A total of 180 patients met initial inclusion and completed the one-month follow-up [% follow-up = 75% (180/240 eligible at initial visit)]: 100 (55.9%) were male, 136 (88.9%) Caucasian, and 28 (15.6%) were injured in football. Median age was 15 years (IQR: 13.0, 16.0). In the QOL model, a 10 point estimated increase in symptom severity score (Beta=-1.825; 95% CI: -3.335, -0.314) and no previous head injury (Mean Difference: -5.751; 95% CI: -11.089 -0.412) were associated with worse one-month QOL. A 0.06 point increase in initial visit ImPACT TM Reaction Time (Beta=-2.120; 95% CI: -3.898 -0.343) was associated with worse one-month MDF in the MDF model. CONCLUSION: Clinicians should be mindful of acute symptom burden and those with no history of concussion when considering potential for worse one-month post-injury QOL outcomes. Those with initial longer reaction times may be more likely to experience fatigue over the first month following concussion. Clinicians may need to consider early intervention in patients with these characteristics. Funded in part by the National Operating Committee on Standards for Athletic Equipment.

Introduction: Sickle cell vaso-occlusive crisis (VOC) is one of the most frequent causes of emergency visit and admission in children with this condition. With this study, we aim to evaluate whether the implementation of an oral morphine protocol has led to improved care of sickle cell disease (SCD), translated by a reduced hospitalization rate, an increased oral administration rate and faster opiate administration time, comparing cohorts of patients presenting to the emergency department (ED) and hematology outpatient clinic (HOC) with VOC pre and post implementation. Methods: Retrospective chart review of patients with SCD followed at CHU Ste-Justine, who presented to the ED and HOC with VOC, in the year pre and post implementation of the protocol. Patients with a VOC diagnosis during the study periods were selected in each department’s database. The primary outcome was to evaluate the hospitalization rate. The rate of oral administration, as well as the opiate administration time from inscription in the ED or arrival in the HOC were also calculated. We estimated that 35 patients per arm would be sufficiently powered to detect at least a 30% rate reduction of admissions, with a power of 80% and a significance of 0.05. Results: Over the two periods, a total of 105 patients (49 pre and 56 post) were included from the ED and 62 patients (36 pre and 26 post) from the HOC. Both departments showed a reduction in hospitalization rate: a difference of 48% (95% CI 32, 61) in ED and 38% (95% CI 13, 57) in HOC. Both showed an increase in the rate of oral administration: a difference of 36% (95% CI 19, 50) in ED and 33% (95% CI 8, 53) in HOC. There was a non-significant difference of 10 min (95% CI -10, 25) in the opiate administration time in ED, as opposed to HOC where a significant difference of -45 min (95% CI -71, -6) was found, with both presenting median times over the recommended 60 minutes post implementation. Both settings showed an increase in the percentage of patients without IVs; a difference of 17% (95% CI 4, 30) in ED and 55% (95% CI 72, 31) in HOC. Conclusion: This study validates the use of our oral morphine protocol for the treatment of VOC, by showing a significant reduction in hospitalization rates. Although delays remain in our opiate administration time, our protocol decreased the number of painful IV procedures.