Damage control resuscitation is a relatively new resuscitative strategy for patients with severe traumatic hemorrhage. This strategy consists of permissive hypotension and early balanced transfusion, and transfers the patients to subsequent surgery. There is growing evidence on harms of excessive fluids. Since 2013, survival benefit of massive transfusion protocol has been proven in adults. Despite insufficient evidence, pediatric massive transfusion protocols are widely used in North American trauma centers. This review focuses on the concept of damage control resuscitation, and summarizes the relevant pediatric evidence.
Adult ; Blood Coagulation Disorders ; Blood Transfusion ; Child ; Emergency Medicine ; Hemorrhage ; Hemostasis ; Humans ; Hypotension ; Hypotension, Controlled ; Resuscitation ; Trauma Centers ; Wounds and Injuries

PURPOSE: This study aimed to investigate the characteristics of poisoning drug ingested by younger children, and to compare the clinical outcome by drug forms.METHODS: This was a retrospective analysis based on medical records from the Emergency Department based Injury In-depth Surveillance (EDIIS) registry in Korea from January to December 2015. Patients aged 7 years or younger visiting the emergency department (ED) with drug poisoning were included. We classified the forms of drugs as tablets or syrup, and analyzed the characteristics by size, color, and shape. In addition, clinical outcomes and ED length of stay were compared according to the drug forms.RESULTS: A total of 308 cases were collected, and 202 patients finally were analyzed. Tablets and capsules (TACs) were more common than syrup (67.3% vs. 32.7%). Regarding clinical outcomes, patients who took TACs had higher admission rate (17.6% vs. 7.6%, P = 0.040) without a significant difference in ED length of stay compared to those who took syrups. While commonly ingested drugs in TACs were hormones, sedative and analgesics, frequent drugs in syrup were antihistamines and cold drugs. In 136 case of TACs, median long and short axes were 0.85 cm (interquartile range [IQR], 0.7–1.1 cm) and 0.72 cm (IQR, 0.59–0.82 cm), respectively. Chromatic TACs were 80 cases (58.8%) and more common than achromatic TACs. Round shapes were preferred than angular ones (96.3% vs. 3.7%).CONCLUSION: In younger children poisonings, the TACs showed higher incidence and admission rate compared to syrups. Especially, chromatic TACs and round shapes were preferred. Therefore, drugs with these characteristics need to be stored more carefully.
Analgesics ; Capsules ; Child ; Dosage Forms ; Drug Compounding ; Emergency Service, Hospital ; Histamine Antagonists ; Humans ; Incidence ; Korea ; Length of Stay ; Medical Records ; Poisoning ; Retrospective Studies ; Tablets

Background: The coronavirus disease 2019 (COVID-19) omicron (B.1.1.529) variant reduced the risk of severe disease compared with the original strain and other variants, but it appeared to be highly infectious, which resulted in an exponential increase in confirmed cases in South Korea. As the number of confirmed cases increased, so did the number of pediatric patients’ hospitalization. This study aims to evaluate the frequency and clinical features of febrile seizure associated with the COVID-19 omicron variant in children. Methods: We retrospectively reviewed the medical records of children aged under 18 years with febrile seizure who were tested for COVID-19 from February 2020 to April 2022 at Ajou University Hospital, South Korea. Based on the dominant variants, we divided the period into the pre-omicron (from February 2020 to December 2021) and omicron periods (from January 2022 to April 2022) and compared the clinical characteristics between the two. Also, we compared the clinical characteristics of febrile seizure between COVID-19 positive and negative group during the omicron period. Results: Among the 308 children, 211 patients (9.2 patients/months) and 97 patients (24.3 patients/months) were grouped into pre-omicron and omicron periods, respectively.Compared with the pre-omicron period, patients in the omicron period showed significantly higher mean age (pre-omicron vs. omicron, 22.0 vs. 28.0 months; P = 0.004) and COVID-19 positive results (pre-omicron vs. omicron, 0.5% vs. 62.9%; P < 0.001). As the COVID-19 confirmed cases in the omicron period increased, the number of COVID-19 associated febrile seizure also increased. In the omicron period, 61 children were confirmed to be positive for COVID-19, and COVID-19 positive group showed statistically significant higher mean age (positive vs. negative, 33.0 vs. 23.0 months; P= 0.003) and peak body temperature than the negative group (positive vs. negative, 39.1°C vs. 38.6°C; P = 0.030). Despite the lack of significance, COVID-19 positive group showed longer seizure time, multiple seizure episodes, and higher prevalence of complex febrile seizure. Conclusion The frequency of COVID-19 associated febrile seizure increased in the omicron periods. In addition, in this period, children with febrile seizure diagnosed with COVID-19 had a higher mean age and higher peak body temperature.

Purpose: This study was performed to investigate the association of high age-adjusted shock index (AASI) with mortality in Korean children with trauma. Methods: The data of children (aged < 15 years) with trauma who visited an university hospital in Korea from 2010 through 2018 were reviewed. High AASI was defined by age groups as follows: < 12 months, ≥ 2.7; 12-23 months, ≥ 2.1; 2-4 years, ≥ 1.9; 5-11 years, ≥ 1.5; and 12-14 years, ≥ 1.1. Age, sex, transfer status, injury mechanism, hypotension, tachycardia, base deficit, hemoglobin concentration, trauma scores, hemorrhage-related procedures (transfusion and surgical interventions), and severe traumatic brain injury were compared according to high AASI and in-hospital mortality. The association of high AASI with the mortality was analyzed using logistic regression. Results: Of the 363 enrolled children, 29 (8.0%) had high AASI and 24 (6.6%) died. The children with high AASI showed worse trauma scores and underwent hemorrhage-related procedures more frequently, without a difference in the rate of the traumatic brain injury. High AASI was associated with in-hospital mortality (survivors, 6.5% vs. non-survivors, 29.2%; P = 0.001). This association remained significant after adjustment (adjusted odds ratio, 6.42; 95% confidence interval, 1.38-29.82). The other predictors were Glasgow Coma Scale (for increment of 1 point; 0.62; 0.53-0.72) and age (for increment of 1 year; 0.84; 0.73-0.97). High AASI showed a 29.2% sensitivity and 93.5% specificity for the mortality. Conclusion High AASI is associated with mortality, and have a high specificity but low sensitivity in Korean children with trauma. This predictor of mortality can be used prior to obtaining the results of laboratory markers of shock.

Purpose: This study was performed to investigate the association of high age-adjusted shock index (AASI) with mortality in Korean children with trauma. Methods: The data of children (aged < 15 years) with trauma who visited an university hospital in Korea from 2010 through 2018 were reviewed. High AASI was defined by age groups as follows: < 12 months, ≥ 2.7; 12-23 months, ≥ 2.1; 2-4 years, ≥ 1.9; 5-11 years, ≥ 1.5; and 12-14 years, ≥ 1.1. Age, sex, transfer status, injury mechanism, hypotension, tachycardia, base deficit, hemoglobin concentration, trauma scores, hemorrhage-related procedures (transfusion and surgical interventions), and severe traumatic brain injury were compared according to high AASI and in-hospital mortality. The association of high AASI with the mortality was analyzed using logistic regression. Results: Of the 363 enrolled children, 29 (8.0%) had high AASI and 24 (6.6%) died. The children with high AASI showed worse trauma scores and underwent hemorrhage-related procedures more frequently, without a difference in the rate of the traumatic brain injury. High AASI was associated with in-hospital mortality (survivors, 6.5% vs. non-survivors, 29.2%; P = 0.001). This association remained significant after adjustment (adjusted odds ratio, 6.42; 95% confidence interval, 1.38-29.82). The other predictors were Glasgow Coma Scale (for increment of 1 point; 0.62; 0.53-0.72) and age (for increment of 1 year; 0.84; 0.73-0.97). High AASI showed a 29.2% sensitivity and 93.5% specificity for the mortality. Conclusion High AASI is associated with mortality, and have a high specificity but low sensitivity in Korean children with trauma. This predictor of mortality can be used prior to obtaining the results of laboratory markers of shock.

Purpose: Base deficit (BD) is superior to vital signs in predicting trauma outcomes in adults. The authors aimed to compare BD and vital signs as criteria for the four-tiered hemorrhagic shock classification in children with trauma. Materials and Methods: We retrospectively reviewed the data of 1046 injured children who visited a Korean academic hospital from 2010 through 2018. These children were classified separately based on BD (class I, BD ≤2.0 mmol/L; II, 2.1–6.0 mmol/L; III, 6.1–10 mmol/L; and IV, ≥10.1 mmol/L) and vital signs (<13 years: age-adjusted hypotension and tachycardia, and Glasgow Coma Scale; 13–17 years: the 2012 Advanced Trauma Life Support classification). The two methods were compared on a class-by-class basis regarding the outcomes: mortality, early transfusion (overall and massive), and early surgical interventions for the torso or major vessels. Results: In total, 603 children were enrolled, of whom 6.6% died. With the worsening of BD and vital signs, the outcome rates increased stepwise (most p<0.001; only between surgical interventions and vital signs, p=0.035). Mortality more commonly occurred in BD-based class IV than in vital signs-based class IV (58.8% vs. 32.7%, p=0.008). Early transfusion was more commonly performed in BD-based class III than in vital signs-based class III (overall, 73.8% vs. 53.7%, p=0.007; massive, 37.5% vs. 15.8%, p=0.001). No significant differences were found in the rates of early surgical interventions between the two methods. Conclusion BD can be a better predictor of outcomes than vital signs in children with severe hemorrhagic shock.

PURPOSE: Oral ondansetron is a safe and effective antiemetic drug to facilitate oral rehydration therapy in acute gastroenteritis (AGE) with mild dehydration. We investigated the effect of oral ondansetron therapy on intravenous (IV) hydration frequency and emergency department length of stay (EDLOS) in dehydrated children with AGE. METHODS: We reviewed 15,813 children aged 12-60 months with primary diagnosis of AGE who visited a tertiary care university-affiliated hospital emergency department. The enrolled children were divided into the pre- (from January 2009 to June 2011) and post- (from January 2016 to June 2018) ondansetron groups according to the implementation of oral ondansetron therapy in the emergency department. As primary outcomes, IV hydration frequency, EDLOS, and hospitalization rate were compared between the 2 groups. As secondary outcomes, EDLOS and hospitalization rate were compared between the children in the post-ondansetron group who underwent the therapy, and those who did not. RESULTS: Of 7,990 enrolled children, 3,300 (41.3%) were designated as the post-ondansetron group, and among them 1,093 (33.1%) underwent oral ondansetron therapy. This group showed a lower IV hydration frequency, a shorter median EDLOS compared to the other group (55.8% vs. 61.9%, P < 0.001; 175.0 vs. 223.0 minutes, P < 0.001, respectively), and a higher hospitalization rate (9.9% vs. 7.9%, P < 0.001). The children in the post-ondansetron group who underwent the therapy showed a shorter median EDLOS and a lower hospitalization rate compared to those who did not (142.0 vs. 205.0 minutes, P < 0.001; 2.9% vs. 13.4%, P < 0.001, respectively). CONCLUSION: Oral ondansetron therapy may reduce IV hydration frequency and EDLOS in dehydrated children with AGE, and can be considered in those having severe vomiting.
Child ; Dehydration ; Diagnosis ; Emergencies ; Emergency Service, Hospital ; Fluid Therapy ; Gastroenteritis ; Hospitalization ; Humans ; Length of Stay ; Ondansetron ; Tertiary Healthcare ; Vomiting

Background: We aimed to investigate changes in the clinical characteristics of pediatric poisoning patients who visited the emergency department (ED) before and during the coronavirus disease 2019 (COVID-19) pandemic. Methods: Poisoning cases below age 18 who visited the ED from January 2018 to December 2021 were retrospectively analysed. The study period was then divided into pre-COVID-19 and COVID-19 pandemic to compare poisoning patterns. Results: During the study period, 86,153 visits to the pediatric ED had been recorded, with 625 patients being included the final analysis. During the COVID-19 period, the proportion of poisoned patients increased from 0.62% to 0.98%. The average age of the patients was higher in the COVID-19 period, with 53.4% of the cases being intentional (pre-COVID-19, 32.5%; P < 0.001). Moreover, 70.4% of poisoning cases during the COVID-19 period were caused by drugs (pre-COVID-19, 60.6%; P = 0.038). More patients underwent decontamination and laboratory investigation during the COVID-19 period than during the previous period (P= 0.007 and P < 0.001, respectively). The length of ED stay and the proportion of hospitalisation were significantly greater during the COVID-19 period. After analysing accidental poisoning cases, we found that antipyreticsonsteroidal anti-inflammatory drugs and respiratory drugs were more common in the pre-COVID-19 group, whereas iron/vitamins, cardiovascular drugs and hormones were more common in the COVID-19 group. After analysing intentional poisoning cases, we found that 73.6% and 76.4% of the patients in the pre-COVID-19 and COVID-19 group had a history of psychiatric disease, respectively. Although no difference was observed in the frequency of previous first suicide attempts, 19.0% of the patients in the COVID-19 group attempted suicide more than three times. Conclusion During the COVID-19 pandemic, intentional poisoning cases, especially in adolescence, increased and were treated more. Many of the patients with intentional poisoning had a history of mental illness or suicide in the past. Therefore, it seems that policy consideration for mentally vulnerable adolescents during this new pandemic period is necessary.

A previously healthy 12-month-old girl presented to the emergency department with vomiting of water beads (superabsorbent polymer). The girl did not have clinical or radiographic signs of residual foreign bodies or intestinal obstruction. Point-of-care ultrasound showed well-demarcated, round, and hypoechoic materials in the stomach and first part of the duodenum, indicating ingested beads. Subsequently, the beads were retrieved by the esophagogastroduodenoscopy. Because water beads can be readily found with point-of-care ultrasound, the use of this imaging modality can expedite endoscopic intervention and avoid surgical removal of foreign bodies.

PURPOSE: The purpose of this study was to compare treatment outcomes between combined gonadotropin-releasing hormone agonist and tamoxifen (GnRHa+T) and sequential adriamycin and cyclophosphamide chemotherapy and tamoxifen (AC->T) in premenopausal patients with hormone-responsive, lymph-node–negative breast cancer. MATERIALS AND METHODS: In total, 994 premenopausal women with T1-T2, lymph-node–negative, hormone-receptor-positive, HER2-negative breast cancer between January 2003 and December 2008 were included in this retrospective cohort study. GnRHa+T and AC->T were administered to 608 patients (61.2%) and 386 patients (38.8%), respectively. Propensity score matching and inverse probability weighting were applied to the original cohort, and 260 patients for each treatment arm were included in the final analysis. Recurrence-free, cancer-specific, and overall survival was compared between the two treatment groups. RESULTS: A total of 994 patients were followed up for a median of 7.4 years (range, 0.5 to 11.4 years). The 5-year follow-up rate was 98.7%, and 13 patients were lost to follow-up. In propensity-matched cohorts (n=520), there was no difference in recurrence-free, cancer-specific, and overall survival rates between the two treatment groups (p=0.306, p=0.212, and p=0.102, respectively), and this was maintained after applying inverse probability weighting. CONCLUSION: GnRHa+T is a reasonable alternative to AC->T in patients with premenopausal, hormone-responsive, HER2-negative, lymph-node–negative, T1-T2 breast cancer.
Arm ; Breast Neoplasms* ; Breast* ; Cohort Studies ; Cyclophosphamide* ; Doxorubicin* ; Drug Therapy* ; Female ; Follow-Up Studies ; Gonadotropin-Releasing Hormone* ; Humans ; Lost to Follow-Up ; Premenopause ; Propensity Score ; Retrospective Studies ; Survival Rate ; Tamoxifen*