Changing patterns of emergency paediatric presentations during the first wave of COVID-19: learning for the second wave from a UK tertiary emergency department.

Background: The SARS-CoV-2 pandemic and initial public health response led to significant changes in health service delivery, access and utilisation. However, SARS-CoV-2 illness burden in children and young people (CYP) is low. To inform effective child public health interventions, we aimed to compare patterns of paediatric emergency department presentation during the initial pandemic response with a previous non-pandemic period. Methods: Retrospective review of attendances (0-18 years) over the initial pandemic (2 March 2020-3 May 2020) compared with 2019. Outcome measures included number of attendances, referral source, presenting complaint, discharge diagnosis and disposal. Descriptive statistics with subgroup analysis by age/sex/ethnicity and pandemic time periods (pre-lockdown, lockdown weeks 1-3 and lockdown weeks 4-6) was performed. Results: 4417 attendances (57% illness and 43% injuries) occurred, compared with 8813 (57% illness and 43% injuries), a reduction of 50%, maximal in lockdown week 2 (-73%). Ranking of top three illness presentations changed across the pandemic weeks. Breathing difficulty dropped from first (300, 25%) to second (117, 21%) to third (59, 11%) (p<0.001). Abdominal pain rose from the third pre-lockdown (87, 7%) and lockdown weeks 1-3 (37, 7%) to second in weeks 4-6 (62, 12%; p=0.004). Fever ranked second (235, 19%) in pre-lockdown and first in weeks 1-3 (134, 24%) and weeks 4-6 (94, 18%; p=0.035). Conclusions: Despite a 50% reduction, there was no significant change in acuity of illness. Rank of illness presentations changed, with abdominal pain ranking second and fever first, an important change from previous, which should prompt further research into causes. CYP-specific public health messaging and guidance for primary care are required in this second wave to ensure access to appropriate emergency services.

Oxygen saturation and haemodynamic changes prior to circulatory arrest: Implications for transplantation and resuscitation.

AIMS: To describe the progression of oxygen saturations and blood pressure observations prior to death. INTRODUCTION: The progression of physiological changes around death is unknown. This has important implications in organ donation and resuscitation. Donated organs have a maximal warm ischaemic threshold. In hypoxic cardiac arrest, an understanding of pre-cardiac arrest physiology is important in prognosticating and will allow earlier identification of terminal states. METHODS: Data were examined for all regional patients over a two-year period offering organ donation after circulatory death. Frequent observations were taken contemporaneously by the organ donation nurse at the time of and after withdrawal of intensive care. RESULTS: In all, 82 case notes were examined of patients aged 0 to 76 (median 52, 4 < 18 years). From withdrawal of intensive care to death took a mean of 28.5 min (range 4 to 185). A terminal deterioration in saturations (from an already low baseline) commenced 14 min prior to circulatory arrest, followed by a blood pressure fall commencing 8 min prior to circulatory arrest, and finally a rapid fall in heart rate commencing 4 min prior to circulatory arrest. Two patients had a warm ischaemic time of greater than 30 min; 15 patients had a warm ischaemia time of 10 min or greater; and 53 patients had a warm ischaemia time of 5 min or less. It was observed that 0/82 patients had saturations of less than 40% for more than 3 min prior to cardiac arrest and 74/82 for more than 2 min. CONCLUSIONS: There is a perimortem sequence of hypoxia, then hypotension, and then bradycardia. The heart is extremely resistant to hypoxia. A warm ischaemic time of over 30 min is rare.