Publications by authors named "Rodrick Lim"

81 Publications

Fruit-Induced Anaphylaxis: Clinical Presentation and Management.

J Allergy Clin Immunol Pract 2021 Mar 13. Epub 2021 Mar 13.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

Background: Data are sparse regarding the clinical characteristics and management of fruit-induced anaphylaxis.

Objective: To assess clinical characteristics and management of patients with fruit-induced anaphylaxis and determine factors associated with severe reactions and epinephrine use.

Methods: Over 9 years, children and adults presenting with anaphylaxis to seven emergency departments in four Canadian provinces and patients requiring emergency medical services in Outaouais, Quebec were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized form documenting symptoms, triggers, and management was collected. Multivariate logistic regression was used to identify factors associated with severe reactions and epinephrine treatment in the pre-hospital setting.

Results: We recruited 250 patients with fruit-induced anaphylaxis, median age 10.2 years (interquartile range, 3.6-23.4 years); 48.8% were male. The most common fruit triggers were kiwi (15.6%), banana (10.8%), and mango (9.2%). Twenty-three patients reported having eczema (9.3%). Epinephrine use was low in both the pre-hospital setting and the emergency department (28.4% and 40.8%, respectively). Severe reactions to fruit were more likely to occur in spring and among those with eczema (adjusted odds ratio [aOR] = 1.12, 95% confidence interval [CI], 1.03-1.23; and 1.17, 95% CI, 1.03-1.34, respectively). Patients with moderate and severe reactions (aOR = 1.23; 95% CI, 1.06-1.43) and those with a known food allergy (aOR = 1.38; 95% CI, 1.24-1.54) were more likely to be treated with epinephrine in the pre-hospital setting.

Conclusions: Severe anaphylaxis to fruit is more frequent in spring. Cross-reactivity to pollens is a potential explanation that should be evaluated further.
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http://dx.doi.org/10.1016/j.jaip.2021.02.055DOI Listing
March 2021

The International Federation of Emergency Medicine pediatric emergency medicine supplement to the model curriculum for emergency medicine specialists.

CJEM 2021 Mar 4;23(2):145-146. Epub 2021 Jan 4.

Servicio de Emergencias, Hospital Nacional de Niños "Dr. Carlos Saenz Herrera", San José, Costa Rica.

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http://dx.doi.org/10.1007/s43678-020-00029-zDOI Listing
March 2021

Implementing virtual care in the emergency department: building on the pediatric experience during COVID-19.

CJEM 2021 01 25;23(1):15-18. Epub 2021 Jan 25.

Children's Hospital of Eastern Ontario (CHEO), University of Ottawa, Ottawa, ON, Canada.

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http://dx.doi.org/10.1007/s43678-020-00026-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7829653PMC
January 2021

A national survey of burnout amongst Canadian Royal College of Physicians and Surgeons of Canada emergency medicine residents.

Can Med Educ J 2020 Sep 23;11(5):e56-e61. Epub 2020 Sep 23.

Schulich School of Medicine and Dentistry, Western University, Ontario, Canada.

Background: In recent years, there has been growing interest in the field of physician wellness and burnout. The prevalence of burnout is non-uniform between medical specialties and is most prevalent amongst emergency medicine physicians. Importantly, burnout can be observed amongst individuals early in their medical careers, including medical students and residents. Despite ample studies in other populations, there is no national perspective of burnout amongst Canadian Royal College of Physicians and Surgeons of Canada (RCPSC)Emergency Medicine (EM) residents.

Methods: Our study surveyed Canadian residents undergoing EM training though the RCPSC via local program directors using an anonymous electronic form. Basic demographic characteristics and residents' contemplation of suicide were surveyed. The Maslach Burnout Inventory - Human Services Survey (MBI-HSS) for medical personnel was used to assess burnout on three dimensions (emotional exhaustion, depersonalization and personal accomplishment).

Results: A total of 65 valid responses were collected from eight of 14 eligible institutions (response rate = 30%). Respondents are primarily male (58%) and in their postgraduate year (PGY) 1-3 (71%). Overall, 62% of residents met the threshold for burnout according to a widely cited definition of burnout using the MBI-HSS. Additionally, 14% contemplated suicide during their training. There was no statistical significance in burnout rates between male and female responders or between residents in different stages of training.

Conclusion: Our results suggest significant burnout amongst Canadian EM residents. These results point to an important opportunity to better support EM residents during their training to improve wellness and reduce burnout.
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http://dx.doi.org/10.36834/cmej.68602DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7522861PMC
September 2020

Comparison of Regularly Scheduled Ibuprofen Versus "Pro Re Nata" for Ankle Sprains in Children Treated in the Emergency Department: A Randomized Controlled Trial.

Pediatr Emerg Care 2020 Dec;36(12):559-563

From the Department of Paediatrics, Western University.

Objective: We compared pain and degree of disability in patients with acute ankle sprains receiving regular scheduled ibuprofen versus pro re nata (PRN).

Methods: This study is a randomized single-blinded controlled trial of children aged 7 to 17 years presenting with acute ankle sprain to an emergency department. Patients were randomized to receive 10 mg/kg of ibuprofen per dose (maximum 600 mg) every 6 hours regular scheduled versus PRN. Outcome measures included a 100-mm visual analog scale pain and degree of disability at day 4. A sample size of 72 children had a power of 80% to detect a clinically meaningful difference of 20 mm between the regular and PRN group.

Results: We randomly assigned 99 patients to receive regular scheduled (n = 50) or PRN (n = 49) ibuprofen. Pain scores and degree of disability at day 4 showed no significant differences between groups. The rate of reported adverse effects was higher in the regular scheduled group (11.4% vs 9.5%) versus the PRN group.

Conclusions: Our study suggests that there is little benefit from routinely using a regular scheduled ibuprofen regimen for acute pediatric ankle sprains.
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http://dx.doi.org/10.1097/PEC.0000000000002282DOI Listing
December 2020

Risk of peanut- and tree-nut-induced anaphylaxis during Halloween, Easter and other cultural holidays in Canadian children.

CMAJ 2020 Sep;192(38):E1084-E1092

Division of Allergy and Clinical Immunology (Leung, Gabrielli, Ben-Shoshan), Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montréal, Que.; Division of Rheumatology (Clarke, Shand), Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Alta.; Department of Emergency Medicine (Morris), Hôpital Sacré-Coeur; Division of Pediatric Emergency Medicine (Gravel), Department of Pediatrics, Centre hospitalier universitaire Sainte-Justine, Montréal, Que.; Division of Pediatric Emergency Medicine (Lim), Department of Pediatrics, Children's Hospital at London Health Sciences Centre, London, Ont.; Divisions of Allergy and Immunology (Chan) and Emergency Medicine (Goldman, Enarson), Department of Pediatrics, BC Children's Hospital, University of British Columbia, Vancouver, BC; Department of Pediatrics (O'Keefe), Faculty of Medicine, Memorial University, St. John's, NL; Food Allergy Canada (Gerdts), Toronto, Ont.; Division of Clinical Immunology & Allergy (Chu), Department of Medicine, and Department of Health Research Methods, Evidence, and Impact (Chu), McMaster University, Hamilton, Ont.; Division of Immunology and Allergy (Upton), Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ont.; Centre for Outcomes Research and Evaluation (Zhang), Research Institute of McGill University Health Centre, Montréal, Que.

Background: It is not established whether the risk of anaphylaxis induced by peanuts or tree nuts in children increases at specific times of the year. We aimed to evaluate the risk of peanut-and tree-nut-induced anaphylaxis during certain cultural holidays in Canadian children.

Methods: We collected data on confirmed pediatric cases of anaphylaxis presenting to emergency departments in 4 Canadian provinces as part of the Cross-Canada Anaphylaxis Registry. We assessed the mean number of cases per day and incidence rate ratio (IRR) of anaphylaxis induced by unknown nuts, peanuts and tree nuts presenting during each of 6 holidays (Halloween, Christmas, Easter, Diwali, Chinese New Year and Eid al-Adha) versus the rest of the year. We estimated IRRs and 95% confidence intervals (CIs) using Poisson regression.

Results: Data were collected for 1390 pediatric cases of anaphylaxis between 2011 and 2020. Their median age was 5.4 years, and 864 (62.2%) of the children were boys. During Halloween and Easter, there were higher rates of anaphylaxis to unknown nuts (IRR 1.66, 95% CI 1.13-2.43 and IRR 1.71, 95% CI 1.21-2.42, respectively) and peanuts (IRR 1.86, 95% CI 1.12-3.11 and IRR 1.57, 95% CI 0.94-2.63, respectively) compared to the rest of the year. No increased risk of peanut- or tree-nut-induced anaphylaxis was observed during Christmas, Diwali, Chinese New Year or Eid al-Adha. Anaphylaxis induced by unknown nuts, peanuts and tree nuts was more likely in children aged 6 years or older than in younger children.

Interpretation: We found an increased risk of anaphylaxis induced by unknown nuts and peanuts during Halloween and Easter among Canadian children. Educational tools are needed to increase awareness and vigilance in order to decrease the risk of anaphylaxis induced by peanuts and tree nuts in children during these holidays.
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http://dx.doi.org/10.1503/cmaj.200034DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7532006PMC
September 2020

An environmental scan of wellness initiatives and programs at Canadian academic emergency medicine programs: How far have we come?

CJEM 2020 Nov;22(6):857-863

Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine and Dentistry, London, ON.

Objectives: We sought to conduct a major objective of the Canadian Association of Emergency Physicians (CAEP) Wellness Committee, an environmental scan of the academic emergency medicine programs across the 17 Canadian medical schools.

Methods: An 89-question questionnaire was distributed to academic heads or wellness leads. The responses were verified by the lead author to ensure that the questions were answered completely and consistently.

Results: While formal wellness programs may exist in varying degrees across the 17 universities, most were found to exist only at local, divisional, or departmental levels. A broad variability of established leadership positions exists. Shift practices varied greatly. In day to day practice, availability for food and debriefing were high and childcare, sleep rooms, and follow-up following critical incidents were low. Sabbaticals existed in the majority of centers. Roughly 50% of departments have gender equity program and annual retreats. Centers report programs for the initiation of leaves (82%), onboarding (64%), and reorientation (94%). Support of health benefits (76%) and pensions (76%) depended on type of appointment and relationship to the university. Fiscal transparency was reported in 53% of programs.

Conclusion: Wellness and burnout are critical issues for emergency medicine in Canada. This comprehensive review of wellness programs identifies areas of strength, but also allows identification of areas of improvement for future work. Individual centers can identify common options when developing or expanding their wellness programs.
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http://dx.doi.org/10.1017/cem.2020.408DOI Listing
November 2020

Emergency medicine physician burnout and wellness in Canada before COVID19: A national survey.

CJEM 2020 09;22(5):603-607

Departments of Emergency Medicine and Medicine, Division of Palliative Care, University of Ottawa, Ottawa, ON.

Introduction: Emergency medicine (EM) is a high-risk specialty for burnout. COVID-19 has had and will continue to have important consequences on wellness and burnout for EM physicians in Canada. Baseline data are crucial to monitor the health of EM physicians in Canada, and evaluate any interventions designed to help during and after COVID-19.

Objectives: To describe the rates of burnout, depression, and suicidality in practicing EM physicians in Canada, just before the COVID-19 pandemic.

Methods: A modified snowball method was used for survey distribution. Participants completed the Maslach Burnout Inventory - Health Services Tool (MBI-HSS), a screening measure for depression (PHQ-9), and a question regarding if the physician had ever or in the past 12 months contemplated suicide.

Results: A total of 384 respondent surveys were included in the final analysis: 86.1% (329/382) met at least one of the criteria for burnout, 58% (217/374) scored minimal to none on the PHQ-9 screening tool for depression, 14.3% (53/371) had contemplated suicide during their staff career in EM, and of those, 5.9% (22/371) had actively considered suicide in the past year.

Conclusion: Canadian EM physicians just before the COVID-19 pandemic had an alarming number of respondents meet the threshold for burnout, confirming EM as a high-risk specialty. This important baseline information can be used to monitor the physical and mental risks to EM physicians during and after COVID-19, and evaluate support for mental health and wellness, which is urgently needed now and post pandemic.
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http://dx.doi.org/10.1017/cem.2020.431DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7369344PMC
September 2020

Standards of Care for Children in Emergency Departments: International Federation of Emergency Medicine Agenda for the Care of Children.

West J Emerg Med 2020 04 21;21(3):581-582. Epub 2020 Apr 21.

Children's Hospital at LHSC, Department of Pediatrics and Medicine, Schulich School of Medicine & Dentistry-Western University, London, Ontario, Canada.

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http://dx.doi.org/10.5811/westjem.2020.2.46917DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7234697PMC
April 2020

Anaphylaxis as a presenting symptom of food allergy in children with no known food allergy.

J Allergy Clin Immunol Pract 2020 09 26;8(8):2811-2813.e2. Epub 2020 Apr 26.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2020.04.033DOI Listing
September 2020

Determination of the Pretibial Soft Tissue Thickness in Children: Are Intraosseous Infusion Needles Long Enough?

Pediatr Emerg Care 2020 Jan;36(1):39-42

From the Departments of Paediatrics and Medicine, Schulich School of Medicine and Dentistry, University of Western Ontario; and Children's Health Research Institute, Children's Hospital, London Health Sciences Centre, London, ON.

Objective: The EZ-IO intraosseous (IO) needle is available in 2 needle sizes for children based on the patient weight. To date, there is no published evidence validating the use of weight-based scaling in children. We hypothesized that pretibial subcutaneous tissue thickness (PSTT) does not correspond with patient weight but rather with age and body mass index (BMI). Our objective was to describe the relationship of a patient's PSTT to their weight, age, and BMI in children less than 40 kg.

Method: One hundred patients who weighed less than 40 kg were recruited prospectively from October 2013 to April 2015 at a tertiary care pediatric emergency department. All sonographic assessments were performed by 1 of 2 emergency physicians certified in point-of-care ultrasound. A single sonographic image was taken over the proximal tibia corresponding to the site of IO insertion. In patients where both sonographers performed independent measurements, a Pearson correlation coefficient was determined. Univariate linear regression was performed to determine the relationship between age, weight, and BMI with PSTT.

Results: One hundred participants were recruited and ranged in age from 10 days to 14 years (mean [SD], 5.01 [3.14] years). Fifty-seven percent of participants were male. Patients' weights ranged from 3.5 to 39.3 kg (mean [SD], 21.42 [9.12] kg), and BMI ranged from 12.1 to 45.0 kg/m (mean [SD], 17.31 [4.00]). The mean (SD) PSTT across participants was 0.68 (0.2) cm. The intraclass correlation coefficient for agreement between the 2 sonographers was moderate (intraclass correlation coefficient, 0.602 [confidence interval, 0.385-0.757]). There were significant positive correlations between BMI and PSTT (r = 0.562, P = <0.001) as well as weight and PSTT (r = 0.293, P < 0.003). There was a weak correlation between age and PSTT (0.065, P = 0.521).

Conclusions: Pretibial subcutaneous tissue thickness correlates most strongly with BMI, followed by weight, and weakly with age. Our findings suggest that current IO needle length recommendations should be based on BMI rather than weight. This would suggest that clinicians need to be aware that young patients in particular with large BMIs may pose problems with current weight-based needle length recommendations.
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http://dx.doi.org/10.1097/PEC.0000000000002019DOI Listing
January 2020

Improving Resident Well-Being During Shiftwork: Are Casino Shifts the Answer?

Pediatr Emerg Care 2019 Dec;35(12):852-855

From the Department of Pediatrics and Medicine, Western University, London, Ontario, Canada.

Purpose: The objective of this study is to quantitatively evaluate the well-being of residents doing casino shifts compared with those doing standard overnight shifts while working in an academic pediatric emergency department.

Methods: A randomized prospective survey study was performed over a period of 1 year on all residents who were scheduled to complete a 28-day block. Each block (28-day period) within the year was designated as either a "standard" or "casino" block. The standard overnight shifts were scheduled from midnight to 0800 hours, and casino shifts occurred from either 2000 to 0400 hours (casino A) and 0400 to 1200 hours (casino B). Participating residents were asked to complete both a preblock and postblock survey. The primary outcome was defined as differences in resident well-being as assessed by the brief resident wellness profile (BRWP). A mood faces graphical rating item to assess overall mood was used as a secondary outcome measures as well as a 10-item survey based on World Health Organization domains for quality of life and adapted to reflect completion of shiftwork.

Results: A total of 124 (90%) of 138 residents completed the study and were included in the analysis. No significant difference in resident well-being measured by BRWP between those in the standard and casino shift groups (17 ± 2.5 for preblock standard and 16.9 ± 2.8 for casino, P = 0.904; 17.1 ± 2.7 for postblock standard and 17.2 ± 3.1 for casino, P = 0.817), or in the relative change of the BRWP preblock and postblock between the 2 groups (standard, 0.35 ± 2.7; casino, 0.29 ± 3.0; P = 0.926). No significant difference in the mood faces rating scale scores or the 10-item postblock survey was found.

Conclusions: In the first study examining the effects of casino shifts on trainees, we found no effect of standard overnight versus casino shifts on their well-being. This counters the benefits previously seen in emergency department consultant staff and highlights the need for more studies specifically in trainees.
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http://dx.doi.org/10.1097/PEC.0000000000001990DOI Listing
December 2019

When and how pediatric anaphylaxis cases reach the emergency department: Findings from the Cross-Canada Anaphylaxis Registry.

J Allergy Clin Immunol Pract 2020 04 31;8(4):1406-1409.e2. Epub 2019 Oct 31.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, QC, Canada.

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http://dx.doi.org/10.1016/j.jaip.2019.10.009DOI Listing
April 2020

Evaluation of Prehospital Management in a Canadian Emergency Department Anaphylaxis Cohort.

J Allergy Clin Immunol Pract 2019 Sep - Oct;7(7):2232-2238.e3. Epub 2019 Apr 26.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

Background: Studies assessing the use of antihistamines and corticosteroids for the treatment of anaphylaxis have not supported a conclusive effect.

Objective: To assess prehospital management of anaphylaxis by measuring the effect of epinephrine use compared with antihistamines and corticosteroids on negative outcomes of anaphylaxis (intensive care unit/hospital ward admission, multiple doses of epinephrine in the emergency department [ED], and intravenous fluids given in the ED).

Methods: The Cross-Canada Anaphylaxis Registry is a cohort study that enrolls anaphylaxis cases presenting to EDs in 5 Canadian provinces over a 6-year period. Participants were recruited prospectively and retrospectively and were excluded if the case did not meet the definition of anaphylaxis.

Results: A total of 3498 cases of anaphylaxis, of which 80.3% were children, presented to 9 EDs across Canada. Prehospital treatment with epinephrine was administered in 31% of cases, whereas antihistamines and corticosteroids were used in 46% and 2% of cases, respectively. Admission to the intensive care unit/hospital ward was associated with prehospital treatment with corticosteroids (adjusted odds ratio, 2.84; 95% confidence interval [CI], 1.55, 6.97) while adjusting for severity, treatment with epinephrine and antihistamines, asthma, sex, and age. Prehospital treatment with epinephrine (adjusted odds ratio, 0.23; 95% CI, 0.14, 0.38) and antihistamines (adjusted odds ratio, 0.61; 95% CI, 0.44, 0.85) decreased the likelihood of receiving multiple doses of epinephrine in the ED, while adjusting for severity, treatment with corticosteroids, asthma, sex, and age.

Conclusions: Prompt epinephrine treatment is crucial. Use of antihistamines in conjunction with epinephrine may reduce the risk of uncontrolled reactions (administration of 2 or more doses of epinephrine in the ED), although our findings do not support the use of corticosteroids.
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http://dx.doi.org/10.1016/j.jaip.2019.04.018DOI Listing
September 2020

Mistaken Asymptomatic Carinal Foreign Body in a Child.

Pediatr Emerg Care 2019 Jan;35(1):e11-e13

From the Departments of Paediatrics and Medicine, Schulich School of Medicine, University of Western Ontario, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada.

Foreign body aspirations are commonly seen in emergency departments (EDs) worldwide, presenting with cough, dyspnea, wheeze, and decreased air entry. Chest radiographs are commonly utilized diagnostic tools to confirm foreign object aspiration. The following is a case report of a child who presented in the ED with a carinal push-pin aspiration and a lack of respiratory symptoms; an extremely rare ED presentation of foreign body aspirations masquerading as a foreign body ingestion. This attests to the importance of conducting a lateral chest radiograph for diagnostic purposes to accurately interpret an esophageal or tracheal foreign body placement.
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http://dx.doi.org/10.1097/PEC.0000000000001707DOI Listing
January 2019

Implementation of a university faculty mentorship program.

Can Med Educ J 2018 Nov 12;9(4):e123-e126. Epub 2018 Nov 12.

Department of Paediatrics and Medicine, Schulich School of Medicine & Dentistry, Ontario, Canada.

Objective: To implement a University Faculty mentorship program in the Division of Emergency Medicine.

Methods: A program based on a unique Schulich faculty mentorship policy was implemented with the help of a Provider Value Officer. The process involved creating a training program which defined the roles of the mentors and mentees and established the principles of an effective mentor-mentee relationship. Faculty received training on how to participate effectively in a Schulich faculty mentorship committee. Each committee consisted of a mentee, and two mentors at the associate professor level (one internal and one external). Thirteen distinct external divisions were represented. They were instructed to meet twice per year, as arranged by the mentee. The mentee created mentor minutes using a template, and then submitted the minutes to the members of the mentorship committee and the Chair/Chief of Emergency medicine. The Chair/Chief used the minutes during the annual Continuing Professional Development meeting.

Results: In less than a year, the division has successfully transformed its mentorship program. Using the above-mentioned process, 31 of 34 (91%) eligible assistant professors have functioning mentorship committees. Collaboration and participation between the different faculties has increased. Follow-up meetings with the Chair/Chief and the Provider Value Officer revealed the theme that, universally, participants have perceived Schulich Faculty Mentorship committees as beneficial and are happy with the "fit" of their mentorship committees.

Conclusion: Through careful planning and training, a successful Faculty Mentorship program can be initiated in an academic division in less than a year with the help of a local champion given protected time.
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http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6260501PMC
November 2018

Refractory Hypotension Caused by Prazosin Overdose Combined With Acetaminophen and Naproxen Toxicity: A Case Report and Review of the Literature.

J Emerg Med 2018 12 2;55(6):e141-e145. Epub 2018 Oct 2.

Department of Pediatrics at Schulich School of Medicine, University of Western Ontario, and the Children's Health Research Institute, Children's Hospital at London Health Sciences Centre, London, Ontario, Canada.

Background: Pediatric exposure to prazosin is unusual because it is most commonly indicated for the treatment of hypertension. Prazosin's increase in popularity as a treatment for posttraumatic stress disorder makes it important for emergency physicians to be aware of how to manage potential toxic ingestion because of prazosin overdose.

Case Report: A 16-year-old, 76-kg female presented after ingesting 110 mg of prazosin, 209.3 g of acetaminophen, and 55 g of naproxen. She was admitted to the pediatric intensive care unit for rapidly deteriorating hypotension (lowest blood pressure 47/19 mm Hg) refractory to aggressive fluid resuscitation and infusions of epinephrine and norepinephrine each at 0.5 mcg/kg/min. Stabilization of blood pressure was eventually achieved, and associated with use of a vasopressin infusion of 0.004 units/kg/min. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because of the increasing exposure of children to prazosin, clinicians should be aware of the pharmacology behind alpha-1 antagonist overdose and consider treatment options, such as vasopressin, when hypotension is resistant to standard fluid and catecholamine therapy.
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http://dx.doi.org/10.1016/j.jemermed.2018.09.015DOI Listing
December 2018

Teenagers and those with severe reactions are more likely to use their epinephrine autoinjector in cases of anaphylaxis in Canada.

J Allergy Clin Immunol Pract 2019 03 28;7(3):1073-1075.e3. Epub 2018 Aug 28.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

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http://dx.doi.org/10.1016/j.jaip.2018.07.044DOI Listing
March 2019

Clinical Suspicion and Language Translation in the Pediatric Emergency Department.

Pediatr Emerg Care 2018 Aug 20. Epub 2018 Aug 20.

From the Departments of Pediatrics and.

Elucidating a medical history and gaining patient consent and buy-in are difficult in any teenager presenting to a North American pediatric emergency department, but especially so when they present with limited English fluency. Translators can make this process easier, but both limited availability and impreciseness in translation can reduce their utility. We describe 2 teenage females who presented to our pediatric emergency department within 48 hours with similar presentations but no obvious organic cause or examination findings to suggest a specific diagnosis. We demonstrate how complex language translation issues in these adolescents contributed to prolonged diagnoses and advocate for independent interpreters to be available on first presentation to hospital.
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http://dx.doi.org/10.1097/PEC.0000000000001606DOI Listing
August 2018

The Acutely Traumatized Child: Advances and Opportunities.

Authors:
Rodrick Lim

Curr Pediatr Rev 2018;14(1)

Associate Professor of Pediatrics Department of Pediatric and Medicine Site Chief Children`s Hospital Emergency Department at LHSC Schulich School of Medicine & Dentistry London, Ontario, Canada.

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http://dx.doi.org/10.2174/157339631401180718111811DOI Listing
May 2019

Pediatric Forefoot Fractures: Assessment of Fracture Patterns and Predictors of Complicated Outcome.

Pediatr Emerg Care 2018 Apr;34(4):233-236

Background: Forefoot fractures account for 6% to 10% of fractures in children, and although the majority heals with supportive treatment, complications may lead to pain and disability. No previous study in children has evaluated complication risk in the emergency department based on initial assessment characteristics.

Study Objectives: The study aim was to identify the radiological and clinical variables that increase the complication rate of pediatric forefoot fractures. This may help emergency physicians refer patients who require more thorough follow-up or surgical intervention.

Methods: We evaluated 497 forefoot fractures on initial presentation to a pediatric emergency department at the Children's Hospital at London Health Science Centre over a 6-year period. We collected variables such as degree of angulation, displacement, number of concurrent fractures, and demographic data such as age and sex. We then determined the variables associated with complications by reviewing each patient's chart.

Results: Overall, there was a 6.4% complication rate. Analysis identified sex as an important predictor of complications. Females, although representing approximately one third of the sample, represented nearly two thirds of the cases with complicated outcomes (P = 0.001; odds ratio [OR], 4.67). Increased number of fractures was also significant (P = 0.01; OR, 2.41) as was increasing age (P = 0.01; OR, 1.17) and patients who chose to return to the emergency department (P < 0.05; OR, 5.282). Lateral angulation/displacement and anteroposterior angulation/displacement were not associated with increased complications.

Conclusion: Identifying features, such as female sex, increasing age, multiple fractures, and return to emergency departments for repeat visits, may help guide the emergency physician on whom to refer for specialized care.
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http://dx.doi.org/10.1097/PEC.0000000000001463DOI Listing
April 2018

The Role of Point of Care Ultrasound in the Injured Paediatric Patient.

Curr Pediatr Rev 2018 ;14(1):41-47

Department of Pediatrics, Schulich School of Medicine, Western University, Ontario, ON, Canada.

The focus of this review is to examine the current state of paediatric Point of Care Ultrasound (POCUS) in the injured patient. POCUS has become useful across various medical specialties owing to its ease of use, reproducibility and non-ionizing qualities. Point of care ultrasound has advanced over the past years and has proven to be an extremely useful adjunct in the injured child. Discussion will center around the challenges on when and how to best utilize POCUS. This includes but is not limited to: detection of peritoneal free fluid, pneumothoraces, hemothoraces, pericardial effusions, a wide array of fractures, lung contusions and many other applications. Discussion will also be focused on the evolution of POCUS, as well as a discussion around the determination of training standards.
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http://dx.doi.org/10.2174/1573396314666180202102853DOI Listing
September 2018

Disparities in rate, triggers, and management in pediatric and adult cases of suspected drug-induced anaphylaxis in Canada.

Immun Inflamm Dis 2018 03 1;6(1):3-12. Epub 2017 Nov 1.

Division of Pediatric Allergy and Clinical Immunology, Department of Pediatrics, McGill University Health Centre, Montreal, Quebec, Canada.

Introduction: Data is sparse on drug-induced anaphylaxis (DIA) and there have not been studies assessing the differences in clinical characteristics and management of DIA between adults and children.

Objective: We assessed the percentage, diagnosis, and management of DIA among all anaphylaxis visits in three pediatric and one adult emergency departments (ED) across Canada.

Methods: Children presenting to the Montreal Children's Hospital (MCH), British Columbia Children's Hospital (BCCH), and Children's Hospital at London Health Sciences Center and adults presenting to Hôpital du Sacré-Coeur with anaphylaxis were recruited as part of the Cross-Canada Anaphylaxis Registry. A standardized data form documenting the reaction and management was completed and patients were followed annually to determine assessment by allergist and use of confirmatory tests.

Results: From June 2012 to May 2016, 51 children were recruited from the pediatric centers and 64 adults from the adult center with drug-induced anaphyalxis. More than half the cases were prospectively recruited. The percentage of DIA among all cases of anaphylaxis was similar in all three pediatric centers but higher in the adult center in Montreal. Most reactions in children were triggered by non-antibiotic drugs, and in adults, by antibiotics. The majority of adults and a third of children did not see an allergist after the initial reaction. In those that did see an allergist, diagnosis was established by either a skin test or an oral challenge in less than 20% of cases.

Conclusions: Our results reveal disparities in rate, culprit, and management of DIA in children versus adults. Further, most cases of suspected drug allergy are not appropriately diagnosed. Guidelines to improve assessment and diagnosis of DIA are required.
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http://dx.doi.org/10.1002/iid3.201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5818453PMC
March 2018

A Rare Case of Cecal Bascule in a Child With Normal Neurodevelopment.

Pediatr Emerg Care 2020 Mar;36(3):e168-e171

From the Departments of Paediatrics and Surgery, Schulich School of Medicine at the University of Western Ontario.

Cecal volvulus is a rare cause of bowel obstruction in adults and an extremely rare presentation in children. One form known as a cecal bascule has only previously been reported in children with neurodevelopmental issues or with severe chronic constipation. We present the case of a 10-year-old boy who presented with an acute history of left lower quadrant abdominal pain, who upon investigation was found to have a cecal bascule.
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http://dx.doi.org/10.1097/PEC.0000000000001309DOI Listing
March 2020

Mallet Finger in a Toddler: A Rare But Easily Missed Injury.

Pediatr Emerg Care 2017 Oct;33(10):e103-e104

From the *Department of Paediatrics, †Division of Plastic Surgery, Department of Surgery, and ‡Division of Emergency Medicine, Department of Medicine, Schulich School of Medicine at Western University; and §Children's Health Research Institute, at the Children's Hospital at London Health Sciences Centre, London, Ontario, Canada.

A mallet finger is a flexion deformity of a finger at the distal interphalangeal joint due to an injury of the extensor mechanism at the base of the distal phalanx. Most common in middle-aged men, injuries in the pediatric population are less common and rare in toddlers. We describe a case of missed mallet finger and its subsequent treatment in a female toddler.
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http://dx.doi.org/10.1097/PEC.0000000000001268DOI Listing
October 2017

Approach to Pediatric Traumatic Brain Injury in the Emergency Department.

Curr Pediatr Rev 2018 ;14(1):4-8

Department of Pediatrics, Schulich School of Medicine, Western University, Ontario, ON, Canada.

Background: Traumatic Brain Injury is a major cause of morbidity and mortality in the pediatric population affecting millions of people yearly. It is important that practitioners have the knowledge and skills to care for these complicated patients, as the initial care can significantly affect the course of the injury. We discuss the initial management of traumatic brain injury based on mild, moderate and severe presentations.

Result And Conclusion: Management strategies to address Intracranial Pressure and Cerebral perfusion pressure, the use of oxygenation and ventilation strategies, temperature, correction of metabolic abnormalities and seizure care are discussed.
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http://dx.doi.org/10.2174/1573396313666170815101258DOI Listing
September 2018

Food-induced anaphylaxis to a known food allergen in children often occurs despite adult supervision.

Pediatr Allergy Immunol 2017 11 30;28(7):715-717. Epub 2017 Aug 30.

Division of Allergy and Clinical Immunology, Department of Pediatrics, Montreal Children's Hospital, McGill University Health Center, Montreal, QC, Canada.

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http://dx.doi.org/10.1111/pai.12770DOI Listing
November 2017