Emergency management of paediatric status epilepticus in Australia and New Zealand: practice patterns in the context of clinical practice guidelines.

AIMS: To establish current acute seizure management through a review of clinical practice guidelines (CPGs) and reported physician management in the 11 largest paediatric emergency departments in Australia (n= 9) and New Zealand (n= 2) within the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network, and to compare this with Advanced Paediatric Life Support (APLS) guidelines and existing evidence. METHODS: (i) Review of CPGs for acute seizure management at PREDICT sites. (ii) A standardised anonymous survey of senior emergency doctors at PREDICT sites investigating management of status epilepticus (SE). RESULTS: Ten sites used seven different seizure CPGs. One site had no seizure CPG. First line management was with benzodiazepines (10 sites). Second line and subsequent management included phenytoin (10), phenobarbitone (10), thiopentone (9), paraldehyde (6) and midazolam infusion (5). Of 83 available consultants, 78 (94%) responded. First line management of SE without intravenous (IV) access included diazepam per rectum (PR) (49%), and midazolam intramuscular (41%) and via the buccal route (9%). First line management of SE with IV access included midazolam IV (50%) and diazepam IV (44%). The second line agent was phenytoin (88%); third line agents were phenobarbitone (33%), thiopentone and intubation (32%), paraldehyde PR (22%) and midazolam infusion (6%). Fourth line agents were thiopentone and intubation (60%), phenobarbitone (16%), midazolam infusion (13%) and paraldehyde (9%). CONCLUSIONS: Initial seizure management by CPG recommendations and reported physician practice was broadly similar across PREDICT sites and consistent with APLS guidelines. Practice was variable for second/third line SE management. Areas of controversy would benefit from multi-centred trials.

Patterns of presentation to the Australian and New Zealand Paediatric Emergency Research Network.

OBJECTIVE: To describe epidemiological data concerning paediatric ED visits to an Australian and New Zealand research network. METHODS: We conducted a cross-sectional study of paediatric ED visits to all Paediatric Research in Emergency Departments International Collaborative (PREDICT) sites in 2004. Epidemiological data, including demographics, admission rates and diagnostic grouping, were examined and analysed using descriptive and comparative statistical methods. We compared the data, if possible, with published data from a US paediatric emergency research network (Pediatric Emergency Care Applied Research Network). RESULTS: A total of 351 440 ED presentations were analysed from 11 PREDICT sites. Mean patient age was 4.6 years and 55% were boys. Presentations were identified as 3% Aboriginal at Australian sites and 44% Maori/Pacific in New Zealand locations. According to Australasian Triage Scale (ATS), 5% were ATS 1 or 2 (to be seen immediately or within 10 min), 27% ATS 3 (to be seen within 30 min) and 67% ATS 4 or 5. Although ED visits peaked in late winter and early spring, admission rates remained unchanged throughout the year with an overall admission rate of 24%. Most frequent diagnoses were acute gastroenteritis, acute viral illness and upper respiratory tract infection. Asthma was the next most common. Pediatric Emergency Care Applied Research Network and PREDICT data showed differences in terms of ethnicity descriptions/distribution and admission rates. CONCLUSIONS: This is the first description of the epidemiology of patient presentations to major paediatric ED in Australia and New Zealand. It details baseline data important to future collaborative studies and for planning health services for children.

Inhaled methoxyflurane as a prehospital analgesic in children.

OBJECTIVE: Despite widespread use of methoxyflurane as an inhaled analgesic by ambulance services in Australia there are no published data as to its use pattern, efficacy and safety in the prehospital setting. We set out to characterize methoxyflurane use in children in the prehospital setting. METHODS: An observational case series was conducted over an 8 month period. Children who received methoxyflurane while being transported to a tertiary children's hospital by ambulance were enrolled. We analysed indications for use, verbal numerical pain scores, adverse events and depth of sedation based on paramedic, patient, parent and ED staff surveys and review of ambulance care records. RESULTS: During the study period 105 patients were enrolled with an age range of 15 months to 17 years (median age 11 years). Methoxyflurane was mainly used for extremity injuries (82%). Paramedic pain scores dropped from a mean of 7.9 (95% confidence interval [CI] 7.5-8.3) prior to methoxyflurane use to 4.5 (95% CI 3.9-5.0) at 2-5 min and to 3.2 (95% CI 2.8-3.7) at 10 min. There were no serious adverse events (one-sided 97.5% CI 0-3%). Mild adverse events occurred in 38 patients (36.2%; 95% CI 27.0-46.1%). Five of 15 (33.3%) patients under 5 years of age were deeply sedated. CONCLUSION: In the present paediatric case series methoxyflurane appears to be an efficacious analgesic with a low adverse events profile. In young children in particular it can briefly lead to deep sedation.

Paediatric Research in Emergency Departments International Collaborative (PREDICT): first steps towards the development of an Australian and New Zealand research network.

Paediatric emergency research is hampered by a number of barriers that can be overcome by a multicentre approach. In 2004, an Australia and New Zealand-based paediatric emergency research network was formed, the Paediatric Research in Emergency Departments International Collaborative (PREDICT). The founding sites include all major tertiary children's hospital EDs in Australia and New Zealand and a major mixed ED in Australia. PREDICT aims to provide leadership and infrastructure for multicentre research at the highest standard, facilitate collaboration between institutions, health-care providers and researchers and ultimately improve patient outcome. Initial network-wide projects have been determined. The present article describes the development of the network, its structure and future goals.