Child with acute weakness: don't forget the salts.

Case summaryA 10-year-old boy presented with severe progressive generalised weakness on a background of 3 days of diarrhoea and vomiting. Vital signs were normal. Peripheral neurological examination revealed grade 1-2 power in all limbs, hypotonia and hyporeflexia. Sensation was fully intact. Cranial nerve examination and speech were normal. The ECG (figure 1) and initial venous blood gas (figure 2) are shown.edpract;107/1/21/F1F1F1Figure 1ECG.edpract;107/1/21/F2F2F2Figure 2Venous blood gas. QUESTION 1: What abnormalities are present on the ECG?Peaked T waves, prolonged PR segment and loss of P waves?Shortening of the QT interval and Osborn waves (J waves)?T wave flattening/inversion, prominent U waves and long QU interval?Prolonged QT interval with multiple atrial and ventricular ectopics? QUESTION 2: How would you manage this patient's hypokalaemia? QUESTION 3: What is the likely diagnosis?Conversion disorder.Myasthenia gravis.Periodic paralysis.Guillain-Barré syndrome.Botulism. QUESTION 4: What interventions can be considered for long-term treatment of this condition? Answers can be found on page 2.

How to perform and interpret the sweat test.

Cystic fibrosis (CF) is the most common life-threatening autosomal-recessive disease affecting Caucasians in the western world. The sweat test is the main diagnostic test for CF. It is indicated as part of the clinical assessment for infants that have picked up on the national neonatal screening programme. It may also be requested where clinical suspicion of a diagnosis of CF exists despite normal screening results. This article outlines the physiological basis behind sweat testing and the technical aspects of performing the test. Indications for performing the test are also considered. The article aims to provide clinicians with a guide to interpretation of results.

How to use the videofluoroscopy swallow study in paediatric practice.

In paediatric practice feeding, eating, drinking and swallowing difficulties are present in up to 1% of children. Dysphagia is any disruption to the swallow sequence that results in compromise to the safety, efficiency or adequacy of nutritional intake. Swallowing difficulties may lead to pharyngeal aspiration, respiratory compromise or poor nutritional intake. It causes sensory and motor dysfunction impacting on a child's ability to experience normal feeding. Incoordination can result in oral pharyngeal aspiration where fluid or food is misdirected and enters the airway, or choking where food physically blocks the airway The incidence is much higher in some clinical populations, including children with neuromuscular disease, traumatic brain injury and airway malformations. The prevalence of dysphagia and aspiration-related disease is increasing secondary to the better survival of children with highly complex medical and surgical needs. This article aims to outline the indications for performing videofluoroscopy swallow (VFS). This includes the technical aspects of the study, how to interrupt a VFS report and some of the limitations to the study.

How to use iron studies.

Iron studies are frequently requested in paediatric practice. They are useful both as a diagnostic tool and as a way of monitoring certain conditions, particularly those causing iron overload. This article outlines the physiology of iron metabolism and discusses laboratory aspects of performing iron studies, including factors influencing interpretation. Clinical scenarios are used to highlight how the tests can be used in different clinical situations.

Calibration of confidence and assessed clinical skills competence in undergraduate paediatric OSCE scenarios: a mixed methods study.

BACKGROUND: The relationship between confidence and competence in clinical skills development is complex but important. This study aims to determine undergraduate paediatric student confidence in performing three common paediatric clinical skills framed as Objective Structured Clinical Examination (OSCE) scenarios and to compare this with subsequent assessed performance. The study also aims to explore possible barriers to successful paediatric skills completion. METHODS: A mixed-methods study was conducted on medical students. Cross-sectional questionnaire data relating to confidence in performing a number of paediatric skills were compared with assessed paediatric skills competency. Focus groups were carried out to identify themes in paediatric skills completion to triangulate this data. RESULTS: Eighty-five medical students participated in the study. Students had high levels of pre-test confidence in their ability to perform paediatrics skills. However agreement between pre-test confidence and subsequent task performance was poor and students had significantly greater belief in their skills ability than was subsequently demonstrated. Focus groups identified paediatric skills complexity, conflicting teaching and having limited supervised skills opportunities and as being possible contributory factors to this discrepancy. CONCLUSIONS: Student paediatric skills confidence is not matched by performance. The reasons for this are diverse but mostly modifiable. A major factor is the lack of supervised skills experience with appropriate feedback to support students in learning to calibrate their confidence against their competence. A number of recommendations are made including the introduction of formative assessment opportunities.

How to use a blood film.

The diagnostic relevance of the blood film cannot be underestimated in the assessment of children with suspected primary or secondary haematological conditions. The blood film not only serves as a diagnostic tool but also allows for screening, monitoring of disease progression and therapeutic response in children with a variety of haematological conditions. This article outlines the appearance of normal paediatric and neonatal blood films. The technical aspects involved in preparing a blood film are discussed. Consideration is given to the indications for preparing a blood film and some of the limitations of blood films. Finally, attempts are made to highlight the role of the blood film in the diagnosis of some common paediatric and neonatal conditions.

Fifteen-minute consultation: the child with pica.

Pica is defined as the persistent ingestion of non-nutritive substances for more than 1 month at an age at which this behaviour is deemed inappropriate. It occurs most commonly in children, in patients with learning disabilities and in pregnancy. The aetiology of pica is poorly understood and is probably multifactorial. Clinical assessment can be difficult. History and examination should be tailored to address potential complications of the substance being ingested. Complications can be life threatening. Pica often self-remits in younger children. In those with learning disabilities, however, pica may persist into adulthood. Management strategies should involve a multidisciplinary approach, and interventions are primarily behavioural in nature. There is limited evidence to support pharmacological interventions in the management of children with pica.

ACTup: advanced communication training simulation enhanced by actors trained in the Stanislavski system.

Strong communication, empathy and interpersonal skills are crucial to good clinical practice. Actors trained in interpretations of the Stanislavski system draw on their own life experience to develop the character. We hypothesised that simulation enhanced by trained actors would be an ideal way for our senior trainees to develop advanced communication skills. We developed a communication training course based on challenging situations which occur in paediatrics like child death and safeguarding. Actors were briefed and invited to develop characters that would behave and respond as a parent/carer might do in complex and stressful clinical scenario. Paediatric trainees then participated in simulations, with a focus on communication skills. Feedback and debrief were provided by a multidisciplinary faculty. The impact of the course was evaluated by analysis of data collected in focus groups held after the simulation. Trainees noted the actor's ability to respond in vivo to emotive situations and felt it was much more effective than their previous experience of simulation with simulated patients without formal training. Actors were able to offer feedback on aspects of body language, tone and use of language from a non-medical perspective. Actors enhanced the realism of the simulations by changing their language and emotional performance in response to the trainee's performance, improving trainee engagement.

Familiarity with the clinical environment, achieved by priming, improves time to antibiotic administration in a simulated paediatric sepsis scenario: a randomised control trial.

AIM: The early administration of antibiotics in sepsis reduces mortality and improves outcomes. This randomised control trial evaluated the effect of environmental priming (EP) on healthcare student performance in a simulated paediatric sepsis scenario. METHODS: Medical and nursing students were randomised into primed and unprimed groups. Primed groups received both direct and virtual priming. Each group completed a standardised simulated sepsis scenario. Time to achieve five key clinical interventions was recorded. Mini focus groups were conducted to explore perceptions of EP. RESULTS: There were 26 primed and 26 unprimed groups. The primed students were quicker to complete all five interventions and statistically significantly quicker to achieving intravenous (IV) access (median 350 s vs 373 s, p=0.02), administering IV antibiotics (median 648 s vs 760 s, p=0.045) and seeking senior help (median 703 s vs 780 s, p=0.02). Primed students did not feel that they had gained any specific advantage from being primed. CONCLUSIONS: EP can improve clinical performance. Implications for practice include incorporating EP of key clinical areas into local induction, standardisation of resuscitation areas and regular use of in situ simulation.

Clinicians' gaze behaviour in simulated paediatric emergencies.

AIM: Differences in the gaze behaviour of experts and novices are described in aviation and surgery. This study sought to describe the gaze behaviour of clinicians from different training backgrounds during a simulated paediatric emergency. METHODS: Clinicians from four clinical areas undertook a simulated emergency. Participants wore SMI (SensoMotoric Instruments) eye tracking glasses. We measured the fixation count and dwell time on predefined areas of interest and the time taken to key clinical interventions. RESULTS: Paediatric intensive care unit (PICU) consultants performed best and focused longer on the chest and airway. Paediatric consultants and trainees spent longer looking at the defibrillator and algorithm (51 180 ms and 50 551 ms, respectively) than the PICU and paediatric emergency medicine consultants. CONCLUSIONS: This study is the first to describe differences in the gaze behaviour between experts and novices in a resuscitation. They mirror those described in aviation and surgery. Further research is needed to evaluate the potential use of eye tracking as an educational tool.