Graded Exercise Testing Predicts Recovery Trajectory of Concussion in Children and Adolescents.

OBJECTIVE: To determine whether graded exercise testing can predict recovery trajectory of concussion in children and adolescents. DESIGN: Prospective study. SETTING: Children's Hospital, Westmead, Australia. PARTICIPANTS: One hundred thirty-nine children aged 12 to 16 years at 5 to 7 days after an acute concussive injury. INTERVENTION: Graded exercise testing on a treadmill at the subacute phase to assess symptom provocation and determine clinical recovery indicating readiness to commence a return to activity (RTA) protocol. Exercise time to symptom exacerbation and clinical recovery were measured. MAIN OUTCOME MEASURES: Standard concussion assessment and clinical testing (neurocognitive, vestibular/ocular, and balance) were conducted to determine major clinical drivers/indicators. RESULTS: Participants (mean age 12.4 ± 2.8 years, 73% male) had a confirmed sport-related concussion. The main clinical drivers identified on exercise testing were headache, balance, and vestibular dysfunction. Participants fell into 1 of 2 groups, exercise-tolerant (54%) and exercise-intolerant (46%). Exercise-tolerant patients showed mild clinical indicators, no symptom exacerbation during 10.3 ± 3.3 minutes of exercise, were safely transitioned to a RTA protocol, and recovered within 10 days. Exercise-intolerant patients had high clinical indicators, significant symptom exacerbation at 4.2 ± 1.6 minutes of exercise, and prolonged recovery of 45.6 days. No adverse effects from exercise were reported in either group. Combined use of provocative exercise and clinical testing was 93% predictive of outcome. CONCLUSIONS: Exercise testing during the subacute phase after a concussion can predict longer recovery. Exercise testing can identify a unique window where patients can be safely transitioned to activity, enabling clinicians to better inform patients and families, allocate resources and streamline care.

Association of Simple Step Test With Readiness for Exercise in Youth After Concussion.

OBJECTIVES: We hypothesized that a submaximal step test would be associated with readiness to commence graded exercise in children and adolescents with concussion. METHODS: Children and adolescents aged 8 to 18 years performed standard concussion clinical assessment for vestibular/ocular and balance impairment, and exercise examination utilizing the 3-minute Kasch Pulse Recovery test (KPR) and a symptom-limited graded exercise test (GXT). Outcome measures included activity readiness and symptom exacerbation. RESULTS: Forty-five participants (mean age 13.2 ± 2.1 years, 76% male) had a confirmed concussion (73% sports-related). Some participants required follow-up testing giving 75 clinical presentations. Sensitivity and specificity of the KPR were 100% and 95.7%, respectively. Area under the receiver operating characteristics curve was 0.979. Activity readiness to GXT and KPR was strongly associated (χ = 21.672, P < .001), while symptom exacerbation showed a significant correlation between testing methods (r = 0.796, P < .001). Better exercise performance on GXT and KPR was significantly correlated with normal Vestibular/Ocular Motor Screening (rs = -0.380, P = .010, and rs = -0.281, P = .017, respectively) and Modified Balance Error Scoring System (rs = -0.452, P < .001, and rs = -0.301, P = .010, respectively). CONCLUSION: The KPR is a simple and practical tool to determine whether it is appropriate for a child or adolescent with concussion to commence graded exercise.

Common sports-related musculoskeletal injuries presenting to the emergency department.

Young athletes are specialising in sports at a younger age, placing the developing musculoskeletal system under considerable stress. Overuse injuries such as apophysitis are chronic in nature and account for a large proportion of musculoskeletal injuries suffered by young athletes; however, with an increased emphasis on success in sport, tendinopathy and fatigue fractures are now being reported with increasing frequency, in the adolescent population. Correct diagnosis and early protection, rest, ice, compression and elevation therapy is critical, along with supervised rehabilitation an expert in paediatric and adolescent sports medicine. Acute traumatic knee injury and ankle sprain account for most acute injuries. Although most are soft tissue in nature, radiography may be useful in specific situations before early initiation of protection, rest, ice, compression and elevation therapy. These injuries will also require follow-up by an expert in paediatric and adolescent sports medicine to confirm the diagnosis and instigate ongoing rehabilitation and/or orthopaedic referral. Many of these injuries are preventable and due consideration should be given to simple prevention strategies.

Concussive head injury in children and adolescents.

BACKGROUND: Awareness of concussive head injury continues to grow, aided by greater understanding of the neurobiological underpinnings of concussions and its short-term and long-term consequences. Younger players who are in the midst of their neurodevelopmental trajectory continue to be placed at risk; therefore, more must be done to educate clinicians, parents, coaches and players alike in this area. Our understanding of concussive injury is evolving and more integrated models of care are being developed so as to provide patients with the holistic model of care needed in the post-concussive context. OBJECTIVE: In this article, we outline a contemporary perspective on concussion, and address an evidence-based approach to children and adolescents who have suffered a concussive injury. DISCUSSION: Good clinical care of a patient with concussion by the primary care physician is the best prevention of adverse outcomes. The ability of the primary care physician to recognise when to treat and when to refer will be an important agent for change in this field.

The nature and characteristics of abdominal injuries sustained during children's sports.

OBJECTIVE: To increase the evidence base by characterizing various features of pediatric sports-related abdominal injuries. DESIGN: A review of the trauma database at The Children's Hospital at Westmead was undertaken for all abdominal injuries presenting to the emergency department between 2001 and 2006. SETTING: The Children's Hospital at Westmead is a tertiary-level pediatric trauma center servicing Sydney's west. It sees approximately 50,000 patients a year. PARTICIPANTS: Only those injuries occurring during an organized sport were included for analysis. Thirty-three of the original 513 patients were eligible for inclusion. MAIN OUTCOME MEASURES: The data collected included basic demographics, mechanism of injury, sport injury, time to presentation, length of stay, diagnoses, treatment, and complications. Injury severity scores were assigned retrospectively. RESULTS: Males sustained more injuries than females. Collisions and falls were the most common modes of injury. Rugby was the most common sport for injury. Most patients presented within 12 hours, and most presented with musculoskeletal injuries. Injury severity was usually mild; treatment, conservative; length of stay, short; and complications, uncommon. When characteristics were compared by sex, males had mostly collision injuries in high-impact/contact sports, with females having more falls in other sports. When characteristics were compared by age, the only statistically significant difference was in the organ injured: older children had more single solid organ injuries, and younger children had more multiple and hollow viscus injuries. CONCLUSIONS: Sports-related abdominal injuries in children are mostly minor and not as common as other injury mechanisms. Despite this, they can be serious, with early diagnosis often delayed because of their subtle nature. Sports-related abdominal injuries in children require a high index of suspicion in the part of the clinician if they are to be recognized early and managed effectively.

Incidence, costs, and temporal trends of sports injury-related hospitalisations in Australian children over a 10-year period: A nationwide population-based cohort study.

OBJECTIVES: To quantify and describe the incidence, cost, and temporal trends of sports injury-related hospitalisations in Australian children over a 10-year period. DESIGN: Retrospective population-based cohort study. METHODS: This study used linked hospitalisation and mortality data of children aged ≤16 years who were hospitalised for sports-related injury in Australia from 1 July 2002 to 30 June 2012. Age-standardised incidence rates were calculated with 95% confidence intervals (CI). Negative binomial regression was used to examine change in temporal trends in incidence rates. RESULTS: There were 130,167 sports injury-related hospitalisations during the 10-year study period. The overall annual incidence rate was 281.0 (95%CI: 279.5, 282.6) per 100,000 population. Males and older children were more frequently hospitalised than their female and younger counterparts. The most common sports activities resulting in hospitalisation were team ball sports (43.1%) and wheeled non-motor sport (22.3%). There was no significant annual decline in the overall incidence rate during the 10-year study period (-1.0% [95%CI: -3.0%, 1.0%]). The estimated total hospital treatment cost was $396 million, with an estimated mean cost per injured child of $3058. CONCLUSIONS: There has been no significant decline in sports injury-related hospitalisation rates among Australian children during 2002-03 to 2011-12. This may suggest that sports injury prevention initiatives in Australia to date have been inadequate to produce population-level reduction in sports injury-related hospitalisations. It is recommended that a national injury prevention strategy to reduce the burden of sports injuries among Australian children is developed and implemented.

Single-dose intravenous salbutamol bolus for managing children with acute severe asthma in the emergency department:Reanalysis of data.

OBJECTIVE: To reanalyze data from two previous studies to provide stronger evidence of benefit for early use of single-dose intravenous bolus salbutamol in children with acute severe exacerbations of asthma. Methods: Randomized, double-blind, placebo-controlled trial of 84 children with acute severe asthma who presented to the emergency department of the Children's Hospital at Westmead. After clinical evaluation, patients who had severe asthma were given high-dose inhaled salbutamol and had an intravenous cannula inserted. Additional treatment consisted of intravenous methylprednisolone (1 mg/kg), oxygen (6 L/min via mask if Sao(2) was <93%). Patients were then randomized to receive an intravenous infusion of either 15 &mgr;g/kg salbutamol or saline, with clinical progress assessed hourly for 2 hrs. All patients were admitted to the hospital and clinically monitored for the proceeding 2-24 hrs, with inhaled salbutamol treatment administered in accord with the hospital's protocol. RESULTS: The intravenous salbutamol group (n = 50) demonstrated earlier clinical improvement, with earlier reduction in oxygen therapy and reduced need for ongoing inhaled salbutamol therapy by the end of phase 1 compared with the control group (n = 34). Patients in the intravenous salbutamol group were ready for discharge from the emergency department 3.7 hrs earlier than those in the control group and were ready for discharge from the hospital 9.7 hrs earlier than controls. No significant side effects were found in either group. CONCLUSION: A single-dose intravenous salbutamol bolus of 15 &mgr;g/kg administered over 10 mins in the initial treatment of children with acute severe asthma in the emergency department has the potential to shorten the duration of severe attacks and reduce overall requirements for inhaled salbutamol maintenance.

The administration of beta2-agonists for paediatric asthma and its adverse reaction in Australian and New Zealand emergency departments: a cross-sectional survey.

AIM: To determine the current use of beta2-agonists, in particular salbutamol, for the management of acute asthma in children in emergency departments throughout Australia and New Zealand. METHODS: A cross-sectional survey using a questionnaire that sought to determine the current use of salbutamol and any adverse drug reactions in paediatric emergency departments. RESULTS: Out of 37 hospitals eligible as paediatric emergency departments, 33 (89.1%) responded to the survey, 54.5% having guidelines for the management of acute asthma. Of the paediatric emergency departments surveyed, 45.5% used metered-dose inhaler spacer combination in the treatment of mild to moderate asthma. All paediatric emergency departments used nebulized salbutamol for acute severe asthma. In addition, 85% of paediatric emergency departments used continuous-infusion intravenous salbutamol in unresponsive patients, 63.6% administering a single-dose intravenous salbutamol bolus before commencing the infusion. District paediatric emergency departments were more likely to treat with continuous-infusion intravenous salbutamol outside of the intensive care unit. Clinical unresponsiveness to inhaled salbutamol and clinical improvement were the reported criteria in all paediatric emergency departments for the use and cessation of intravenous salbutamol. Adverse drug reactions were common: tremor (90%), hypokalaemia (45.5%) and supraventricular tachycardia (21%), particularly if continuous-infusion intravenous salbutamol administered. Eight deaths from asthma were reported, none being related to adverse drug reactions. CONCLUSION: We report a wide variation of salbutamol use in paediatric emergency departments and a high prevalence of type A adverse drug reactions when continuous-infusion intravenous salbutamol therapy was administered. More evidence is needed on the clinical significance of the adverse effects reported in this study and optimal doses for the safe use of continuous-infusion intravenous salbutamol therapy in paediatric emergency departments.

Femoral nerve block for femoral shaft fractures in a paediatric Emergency Department: can it be done better?

BACKGROUND: The relatively simple technique of administering a femoral nerve block is known to be quick, safe and effective in providing prolonged analgesia to children with femoral shaft fracture. Although medical literature supports its use in the emergency setting, no studies have been conducted on how this is undertaken in practice. OBJECTIVE: The aim of this study is to describe the practice of femoral nerve block in previously well children who present to our Emergency Department with femoral shaft fracture. SETTING: This study was conducted at the Emergency Department of a tertiary paediatric hospital in Sydney, Australia. METHODS: A retrospective descriptive study was conducted by gathering data on all patients presenting to the Emergency Department between 1 January 1996 and 1 July 2001 with traumatic fracture to the femoral shaft. Whether femoral nerve block had been performed in the emergency setting; the time taken for femoral nerve block to be performed; the type of local anaesthetic used; the dose of local anaesthetic administered, and the level of training and area of expertise of doctors performing the femoral nerve block were determined from the clinical records. One-way analysis of variance and Student's t-tests were conducted to compare the average dosages of local anaesthetic used by the different medical sub-specialities involved. Student's t-tests were applied to analyse the time differences for performing femoral nerve block between emergency- and non-emergency-based medical staff. RESULTS: The majority (111) of the 117 patients who met the inclusion criteria for the study had isolated femoral shaft fractures (94.9%). Femoral nerve blocks were performed in 97 of our study patients (82.9%). No correlation was found between the age of the child and the time taken for a femoral nerve block. In 76 cases in which a femoral nerve block was given (64.9%), a member of staff external to the Emergency Department performed the procedure. The average time taken for a femoral nerve block to be performed for non-Emergency Department medical staff was significantly longer than for Emergency Department medical staff. In only 37 cases (31.9%), was a femoral nerve block administered within an hour of the time of triage. Doses used by non-anaesthetists were lower than those used by anaesthetists. CONCLUSION: There is unnecessary delay in carrying out this procedure for children with fractures to the femoral shaft. A significant degree of reliance on staff external to the Emergency Department was reported. This paper supports increased training and supervision to promote the more widespread and prompt use of femoral nerve blocks as an important standard of care for the Emergency Department.

Bystander basic life support: an important link in the chain of survival for children suffering a drowning or near-drowning episode.

Eight children suffered drowning or near-drowning in Sydney pools over an 11-day period in January 2007. Four received basic life support (BLS) within 5 minutes of immersion and survived with good functional neurological outcomes. The other four were not discovered for >or= 5 minutes and all died. This cluster serves as a reminder that timely effective bystander BLS is crucial to survival and good clinical outcomes in near-drowning episodes.

Isolated extradural hematoma in children presenting to an emergency department in Australia.

BACKGROUND: Isolated extradural hematoma (EDH) is becoming more frequently recognized in emergency departments (EDs) in children. We describe the natural history of children with isolated EDH presenting to a large Children's Hospital ED. METHODS: This is a descriptive case series study using a retrospective review of the medical records of children presenting to the ED with a diagnosis of isolated EDH over 8 years. Comparison was made with children having other injuries in addition to EDH. The cause, nature of injury, presentations to hospital, management, outcome, and any association with nonaccidental injuries (NAI) were analyzed. RESULTS: Of the 35 cases with a final diagnosis of isolated EDH initially presenting to the ED, 70% were over 3 years of age (mean 6.6 years), and 60% were boys. A fall of less than half a meter was the cause of isolated EDH in 51.4% of patients. The remaining cases resulted from a fall from a height greater than half a meter (17.1%), a motor vehicle accident (11.4%), being hit by an object (8.6%), a bicycle accident (5.7%), and a skateboard accident (5.7%). Children younger than 3 years presented within 24 hours of injury in 70% of cases, compared with 65% of older children. In 95% of cases, presentation was nonspecific, suggesting a medical rather than a surgical problem. This resulted in a delay in seeking emergency care and a delay in final diagnosis for these patients. Surgical drainage was required in 68.6% of cases, with older children being more likely to be managed conservatively. In 23.4% of cases, minor residual neurologic deficit occurred; there were no cases of serious long-term problems. There were no cases of NAI in the children studied. CONCLUSION: This report highlights falls as a common cause of isolated EDH in children. Delay in presentation for clinical assessment is common, because many children have nonspecific presentation that is suggestive of a medical problem. No cases of NAI were reported in this study.

The usefulness of a modified adult protocol for the clearance of paediatric cervical spine injury in the emergency department.

OBJECTIVE: To determine if the use of a modified adult protocol that uses cervical spine imaging on presentation for the assessment of cervical spine injury in children improves clinical outcome. METHODS: This is a case series study on all consecutive trauma patients presenting from April to July 2000 inclusive to the ED of a major paediatric trauma hospital. Children presenting to the ED with potential cervical spine injury (CSI) were identified using standard selection criteria. Patient demographics, mechanism of injury, method and time of presentation, associated injuries, radiological investigation and clinical outcome were recorded. The major outcome measures for this study were: time to clearance of the cervical spine, length of stay in the ED and admission to an in-hospital bed. Data were analysed for compliance to the protocol, this being the standard assessment pathway of cervical spine clearance used by our trauma service. RESULTS: The trauma registry identified 1721 trauma presentations during the 4-month study period; 208 presentations representing 200 children with potential CSI were entered into the study. Males represented 72.5% of the study population, having a mean age of 8.32 years, although 29% were less than 5 years of age. The majority of presentations (69%) occurred outside of normal working hours. In 17.8% of cases the cervical spine was cleared based on clinical assessment alone, half less than 5 years of age. Compliance to the protocol occurred in 78% of presentations. However, when examined by age group, children 5 years of age or above were 1.5 times more likely to comply with the protocol as compared with younger children. Adequate plain imaging was not obtained in 18% of presentations, this group almost exclusively less than 5 years of age. There were no missed injuries and no short or long-term neurological sequelae reported during this study. There were no differences in time to clearance, length of stay and admission rate between compliant and non-compliant groups. CONCLUSIONS: Modified adult protocols for cervical spine clearance offer guidance in managing the majority of children suffering blunt trauma. However, we recommend caution in rigidly applying such protocols, especially to children of young age.

Traction splinting of femoral shaft fractures in a paediatric emergency department: time is of the essence?

OBJECTIVE: To describe the use of traction splinting in children with femoral shaft fracture and to determine if timing of traction splinting application effects outcome. METHODS: A retrospective descriptive study conducted over a five and a half year period (1 January 1996 to 1 July 2001) on children presenting with femoral shaft fracture to a Paediatric trauma centre. Data were collected on all children with a radiological diagnosis of fracture to the femoral shaft. Evidence for hypovolaemic shock and neurovascular compromise was sought. The administration of parenteral analgesia and whether a validated pain scale was employed to monitor pain relief was documented. The use of traction splint or other leg splint device before arrival in the ED and subsequent changes to splinting in hospital were noted. Times to perform radiographic examination and femoral nerve block were also recorded. RESULTS: Ninety-five (95) patients met the study inclusion criteria with 66.3% having some form of immobilization and 70% administered parenteral analgesia in the pre-hospital setting. In only 7.3% of patients was a Thomas splint traction applied within 2 h of arrival. Adverse clinical outcome was not reported in any patient regardless of time to application of Thomas splint traction. The application of Thomas splint traction in the ED resulted in a significant delay in the performance of diagnostic radiographs and femoral nerve block. CONCLUSIONS: The timing of traction splinting is not associated with poor outcome in isolated paediatric femoral shaft fracture provided effective analgesia has been administered in a timely fashion.

Are children with femoral fracture haemodynamically unstable?

OBJECTIVE: To assess the occurrence of hypovolaemic shock in children who have sustained traumatic femoral fracture. METHODS: A retrospective descriptive study was performed on a cohort of children with traumatic femoral fracture presenting over a five and a half year period from 1 January 1996 to 1 July 2001. Selected parameters for analysis included administration of a fluid bolus, as well as all available vital signs within 4 h following injury relating to pulse, systolic blood pressure, respiratory rate, skin capillary refill time and mental status. Fluid and blood transfusion records were examined, as was the need for intraosseous access. Initial haemoglobin and haematocrit results were also obtained. RESULTS: There was no evidence for haemodynamic instability in the 100 patients who met the selection criteria when compared with internationally accepted normal vital sign parameters. No significant difference was found in the initial vital signs between patients who received fluid bolus and those that didn't. No patient needed intraosseous access or fluid resuscitation. One patient received blood transfusion without evidence of haemodynamic instability. Haemoglobin and haematocrit values were not significantly decreased. Ninety-two percent of patients in this study had isolated femoral fracture. CONCLUSIONS: No evidence for haemodynamic instability was found in a cohort of children with traumatic femoral fracture.

Randomized, double-blind, placebo-controlled trial of intravenous salbutamol and nebulized ipratropium bromide in early management of severe acute asthma in children presenting to an emergency department.

BACKGROUND: In acute severe asthma, treatment must be initiated early to reverse the pathophysiology that may render airways less responsive to bronchodilation. The addition of nebulized ipratropium bromide to initial emergency department therapy improves pulmonary function, but it is unclear whether this approach results in earlier hospital discharge. The early use of bolus intravenous salbutamol has also been shown to improve outcome, including earlier discharge. We therefore assessed the relative benefits of intravenous salbutamol and nebulized ipratropium bromide in the early management of acute severe asthma in children by a double-blind, randomized, controlled trial. METHODS: This study was undertaken at a tertiary children's hospital, The Children's Hospital at Westmead, The Royal Alexandra Hospital for Children, Westmead, Sydney, Australia. Only children with severe acute asthma as determined by the National Asthma Campaign guidelines criteria and pulmonary index were included. All children received initial nebulized salbutamol therapy (2.5-5 mg salbutamol in 4 mL of normal saline depending on age) at initial emergency department presentation. If asthma remained severe 20 mins later, an intravenous cannula was inserted and intravenous methylprednisolone (1 mg/kg) was administered to all children receiving nebulized salbutamol every 20 mins. Children were then randomized to one of three groups: intravenous salbutamol (15 microg/kg as a single bolus over 10 mins), ipratropium bromide (250 microg), or intravenous salbutamol plus ipratropium bromide. All observers were blinded to treatment groups. Children were randomly assigned to receive a single-dose intravenous bolus of either saline or salbutamol and either nebulized saline or ipratropium bromide determined by a number generated randomly in the hospital pharmacy. The primary outcomes were recovery time and discharge time of each group. Respiratory and hemodynamic monitoring were continuous during the first 2 hrs of the study and then children were monitored clinically for 24 hrs. RESULTS: A total of 55 children with acute severe asthma were entered into the study over an 18-month period. The three groups were similar demographically, with a mean age of 5.9 yrs, and mean duration of attack of 19.6 hrs. No side effects or treatment intolerance were reported. Children in the groups that received intravenous salbutamol had a significant reduction in recovery time to achieving second hourly inhaled salbutamol (p =.008) compared with those administered inhaled bronchodilator alone. The addition of ipratropium bromide to intravenous salbutamol provided no significant further benefit in terms of nebulizer therapy (intravenous salbutamol compared with intravenous salbutamol plus ipratropium bromide). Children administered intravenous salbutamol ceased supplemental oxygen therapy earlier than those administered ipratropium alone at 12 hrs post-randomization (p =.0003). Children administered intravenous salbutamol could be discharged from the hospital 28 hrs earlier than those administered ipratropium bromide (p =.013). CONCLUSION: Children administered intravenous salbutamol for severe acute asthma showed a more rapid recovery time, which resulted in earlier discharge from the hospital than those administered inhaled ipratropium bromide. There was no additional benefit obtained by combining ipratropium bromide and intravenous salbutamol administration.