Frenal injury in children is not pathognomic of non-accidental injury.

Upper labial frenal tear in infants is classically taught as having associations with non-accidental injury. Collection of data for a 12-month period in our paediatric facial injury study revealed that this injury pattern is common in ambulant children and was associated with other facial trauma. In assessing the possibility of this injury being due to abuse, the importance of the mobility of the child and the mechanism of the injury are paramount.

Facial injury patterns in a UK paediatric population aged under 13 years.

BACKGROUND: The aims of this study were to present the demographics and mechanisms of facial injury in UK children, and to establish the nature and anatomical location of facial injury in this age group. METHODS: Patient data were collected retrospectively over 1 year from a paediatric Emergency Department in South East Scotland. Medical notes were examined for all patients coded on the electronic patient record as having any facial injury. RESULTS: 593 patients attended with a facial injury. The median age of patients was 4.7 years. (IQR 2.4-7.5 years.), and the male to female ratio of facial injuries was 2:1. Injuries were predominantly from falls. Assault or violence was uncommon. Most common sites of facial injury were the lower third of the face and dento-alveolar injury. Facial fractures were rare and radiographic facial imaging was infrequently performed. Only eight facial fractures were diagnosed. 4.5% of all patients were admitted to hospital; 23% of the children were referred on to other specialities for follow-up, of these over half were to a dentist. CONCLUSIONS: A large number of children presented with facial injuries during the study period. Facial lacerations, oral trauma and dental trauma were the most common injuries. The majority of patients were dealt with without admission or referral to another speciality.

Modulating effect of apolipoprotein E polymorphisms on secondary brain insult and outcome after childhood brain trauma.

OBJECTIVE: The aim of this study was to determine the relationship between apolipoprotein E (APO E) alleles, the amount of cerebral perfusion pressure (CPP) insult and outcome in children after brain trauma. MATERIALS AND METHODS: In a prospective two-centre case-control study, the APO E genotypes of 65 critically ill children admitted after brain trauma were correlated with age-related CPP insult quantification, conscious state at the time of discharge from intensive care and global outcome at 6 months post-injury. One hundred sixty healthy age- and sex-matched children were genotyped as controls. RESULTS: The CPP insult level among the e4 carriers with poor outcome was significantly less than the non-e4 carriers (p=0.03). Homozygotic e3 patients with good recovery did so despite having suffered nearly 26 times more CPP insult than those who were not e3 homzygous (p=0.02). CONCLUSION: Different APO E alleles may potentially affect cerebral ischaemic tolerance differently in children after brain trauma.

Exploring the clinical utility of blood ketone levels in the emergency department assessment of paediatric patients.

BACKGROUND: Ketonuria (on standard urine testing) is a frequent finding in children presenting to emergency departments. With the advent of hand-held ketone meters, blood ketone levels can now be rapidly quantified. HYPOTHESIS: Point of care testing (POCT) of blood ketone levels could provide clinically useful information on severity of illness in children and risk of hospital admission. METHODS: A prospective study using POCT of blood ketone levels in a convenience sample of children <13 years old, with a typical case mix of medical problems. FINDINGS: 186 children were studied. The range of ketone levels varied widely among this study population depending on the presenting complaint. Higher levels were noted in those presenting with anorexia or vomiting and fever. The median ketone level of the total study population was 0.2 (range 0-6.0, interquartile range 0.1-0.9) mmol/l. Ketone levels correlated poorly with discharge destination and duration of admission. However, receiver-operator characteristics for ketones as a predictor of admission were comparable to Pediatric Risk of Admission scores (area under the curve 0.64 and 0.72, respectively) and may represent an independent risk factor for admission. A ketone level >1.2 mmol/l has a positive predictive value of 66.7% for admission. Ketone levels correlated well with decreased oral intake (R2 = 0.25; p<0.001). CONCLUSIONS: A strong association was found between ketone levels, decreased oral intake and fever. Although ketone levels do not correlate well with more traditional markers of illness severity, they can help to predict the requirement for admission to hospital when interpreted in the context of the presenting illness. They may have applications in both the emergency department and primary care settings. Further prospective testing is required to validate these findings.

Streptococcus A in paediatric accident and emergency: are rapid streptococcal tests and clinical examination of any help?

BACKGROUND: Rapid streptococcal tests (RSTs) for streptococcal pharyngitis have made diagnosis at once simpler and more complicated. The American Academy of Pediatrics recommends that all RSTs be confirmed by a follow up throat culture unless local validation has proved the RST to be equally sensitive. AIMS: To evaluate (a) RST as a single diagnostic tool, compared with RST with or without throat culture; (b) clinical diagnosis and the relative contribution of different symptoms. METHODS: The study included 213 patients with clinical signs of pharyngitis. Throat swabs were analysed using Quickvue+ Strep A Test; negative RSTs were backed up by throat culture. Thirteen clinical features commonly associated with strep throat were analysed using backward stepwise logistic regression. RESULTS: Positive results (RST or throat culture) were obtained in 33 patients; RST correctly identified 21. Eleven samples were false negative on RST. At a strep throat prevalence of 15.9%, sensitivity of RST was 65.6% (95% CI 46.8% to 81.4%) and specificity 99.4% (96.7% to 99.9%). Sensitivity of clinical diagnosis alone was 57% (34% to 78%) and specificity 71% (61% to 80%). Clinically, only history of sore throat, rash, and pyrexia contributed to the diagnosis of strep throat (p<0.05). CONCLUSION: The high specificity of RST facilitates early diagnosis of strep throat. However, the low sensitivity of RST does not support its use as a single diagnostic tool. The sensitivity in the present study is markedly different from that reported by the manufacturer. Clinical examination is of limited value in the diagnosis of strep throat. It is important to audit the performance of new diagnostic tests, previously validated in different settings.

Contact burns from hair straighteners: a new hazard in the home.

This series highlights a previously unreported hazard for children within the home, hair straightening irons. Thermal injury is a common reason for presentation at the emergency department. Contact burns from domestic irons and hair curling tongs are well documented in the literature. We have become aware of this new hazard in the home, which has resulted in several presentations to our department with deep partial thickness or full thickness burns.

Benign acute childhood myositis in an accident and emergency setting.

Four children presented to the Accident and Emergency department of the Royal Hospital for Sick Children in Edinburgh during seven days in February 2003. They shared a strikingly similar clinical picture with debilitating muscle pain in their calves. This paper discusses their clinical course and presents a literature review of the problem.

Incidental radiological diagnosis of rickets.

Rickets fortunately remains rare in the United Kingdom, although its actual incidence is currently undetermined.1 Many still consider it to be a disease of poverty prevalent during the Victorian era. However, a number of recent articles have highlighted concern among British health professionals about the number of cases still being diagnosed in this country. These cases have nearly all involved non-Caucasian children who are considered to be at high risk due to skin colour, prolonged breast feeding, and low maternal vitamin D levels. Their presentations are variable ranging from failure to thrive, bone deformities, seizures, and even stridor. The diagnosis is usually made in babies and toddlers.We present a series of patients attending our accident and emergency (A&E) department, over a five month period, where the diagnosis of rickets was primarily a radiological diagnosis.

Socioeconomic status and adolescent injuries.

Injuries are the major cause of morbidity among children and adolescents in developed countries, but there is a lack of consensus on the relationship between socioeconomic status and risk of injuries. A self-complete questionnaire survey, to gather information on non-fatal injuries and sociodemographic details, was administered in schools during April-June 1994 to a national sample of 4710 Scottish adolescents aged 11, 13 and 15 years. Although there was no evidence of a socioeconomic gradient in the total incidence of medically attended injuries among adolescents, based on the Registrar General's classifications of paternal occupation and a composite measure of family affluence, marked socioeconomic variation in the circumstances in which injuries occurred was observed. There were also socioeconomic differences in the extent and type of risk behaviours reported by adolescents, indicating differential rates of risk exposure. The finding that socioeconomic status affects the kinds of injury events adolescents experience and levels of risk behaviour has implications for the design of injury prevention strategies.

The limping child: epidemiology, assessment and outcome.

We investigated the epidemiology, assessment and outcome of acute atraumatic limp in 243 children under the age of 14 years presenting to a paediatric accident and emergency department (AED) over a period of six months. Data were collected at presentation and medical notes were re-examined after 18 to 21 months. The incidence of limp was 1.8 per thousand. The male:female ratio was 1.7:1 and the median age 4.35 years. Limp was mainly right-sided (54%) and painful (80%); 33.7% of the children had localised pain in the hip. A preceding illness was found in 40%. The main diagnosis was 'irritable hip'/transient synovitis (39.5%); Perthes' disease accounted for 2%. Most patients (77%) were managed entirely in the AED. Acute atraumatic limp is a common problem in children presenting to the AED. Most can be safely managed there if guidelines are followed and will have a benign outcome. Further studies are needed to identify the role of preceding illness in the aetiology of acute atraumatic limp.

Validation of a computer model of haemorrhage and transcapillary refill.

A computer model is described which uses blood volume deficit and its duration to simulate the first two hours of haemorrhage, including an estimation of the blood volume added by Starlings transcapillary refill mechanism. Computer prediction of the haematocrit was compared with published data on haemorrhage in animals. There was close correlation with data on the haemodilution caused by Starling's transcapillary refill mechanism in conscious swine (r = 0.84).

Prehospital emergency care.

Prehospital care is a diverse and complex entity. Recent studies have begun to emphasize the importance of all aspects of care in the community, leading through to critical analysis of the process of prehospital care provision. This paper examines the various aspects of prehospital care and discusses the various elements which need to be considered to provide effective care prior to patients being attended to at hospital.

Transient synovitis: is there a need to aspirate hip joint effusions?

There is debate as to the optimal management of children with hip joint effusions especially regarding the decision to aspirate. The objective of this study was to determine whether there is a need to aspirate hip joint effusions detected on ultrasound in patients with clinical transient synovitis (TS) and to identify the natural history of these effusions. Twenty-five children with proven hip joint effusions were followed up sequentially by clinical and radiological examination until symptom free. The mean age was 6 years with equal right/left distribution. No child underwent hip aspiration and no cases of sepsis were missed. The median size of hip effusion detected on ultrasound at presentation was 9 mm. At 7 days 60% (15/25) of patients had a normal clinical examination with no detectable effusion on ultrasound. At 14 days 16% (4/25) had an effusion detectable on ultrasound but they were all pain and limp free and their effusions were reducing in size. These results support the known benign nature of TS and that it will settle with conservative treatment.

Use of analgesia in a paediatric accident and emergency department following limb trauma.

The objective of this study was to assess analgesic use and the use of a pain scoring system on those children presenting to a paediatric accident and emergency (A&E) department with a history of injury due to trauma. A random sample of patients who presented to a paediatric A&E department over a 6-week period with a history of limb trauma were prospectively studied. Pain severity scores were assessed on arrival and at 10, 30 and 60 minutes using the Douhit Faces Scale and any analgesia given or plaster application was noted. One hundred and seventy-two patients were studied. The median age was 10 years (range 3-13 years) and the majority, 56%, were male. The mean initial pain scores were 2.7 (range 1-4) for boys and 3.0 (range 1-4) for girls. The presenting injuries were 103 upper or lower limb fractures and 69 'soft tissue' injuries. Only 84 (49%) patients received analgesic medication in the department (30% morphine; 70% paracetamol); analgesia was not given to the remaining 88 (51%). Of these, 7 declined analgesia, and 5 had already taken analgesia on arrival to A&E. Despite prompt triage (median time 2 minutes, range 0-10 minutes), the median time from arrival to paracetamol administration was 20 minutes (range 4-105 minutes) and for morphine was 14 minutes (range 2-57 minutes). Pain is a common symptom in patients presenting to A&E. Because children's pain can be particularly difficult to assess, a pain scoring system such as the Douhit Faces Scale can be a useful means of pain assessment in the A&E setting. Despite increased awareness, pain is still under treated in the A&E department.

Comparison of oral and intravenous morphine following acute injury in children.

The objective of this research was to examine the speed of onset and effectiveness of pain relief between oral and intravenous morphine in acutely injured children. An observational study of children aged 3 to 13 years with closed forearm fractures was performed in three accident and emergency departments. The study gathered information on age, gender, body weight, time of arrival, dose, route and time of morphine administration. Pain assessment using a Faces Scale was documented on arrival and repeated at 10, 30 and 60 minutes after morphine was given. Forty-seven children were studied. Of these, 25 were given intravenous morphine, 22 were given oral morphine. There was no statistically significant difference in age, body weight or time until morphine was administered. The change in median pain scores was analysed using the Mann-Whitney U test. This showed that there was a statistically significant reduction in pain score in the intravenous group compared with the oral group between arrival and 10 minutes after giving morphine and between arrival and 60 minutes after giving morphine. Intravenous morphine appears to give more rapid onset and more prolonged pain relief than oral morphine for children with acute injuries. We recommend that in accident and emergency departments where staff are experienced in paediatric cannulation, morphine should be given via the intravenous route in acutely injured children. However we do not advocate inexperienced staff attempting multiple venepunctures in a child resulting in increased anxiety.

Hanging arm method for reduction of dislocated elbow.

This paper describes two patients with posterior dislocation of the elbow in whom the dislocation was reduced atraumatically by a modified hanging arm method not previously described. Further research is recommended to evaluate this method.

How do blood cultures sent from a paediatric accident and emergency department influence subsequent clinical management?

OBJECTIVES: To determine the clinical impact of positive results from blood cultures sent from a busy paediatric accident and emergency department. METHODS: All children who attended the department over a seven month period and had blood culture investigations were identified. Case notes of patients who had any growth on blood culture were reviewed to determine whether the organism was felt to be pathogenic and how the result affected clinical management. RESULTS: 1159 children had blood cultures sent, 26 of these grew an organism that was felt to be pathogenic. However, only five significantly influenced clinical management. CONCLUSIONS: Blood cultures sent from an accident and emergency department rarely influence clinical management. A more focused approach to bacteriological investigation is recommended.

Wavelet analysis of pulse oximeter waveform permits identification of unwell children.

BACKGROUND: Children who are unwell often display signs of circulatory compromise. It has been observed that pronounced changes occur in the appearance of the photoplethysmogram (pulse oximeter tracing) in these children. The aim of the study was to discover if wavelet transforms can identify more subtle changes in the photoplethysmogram of children who are unwell. METHODS: Photoplethysmograms were obtained from children attending a paediatric accident and emergency department with clinical features suggestive of significant bacterial illness or circulatory compromise. Photoplethysmograms were also obtained from a control group of well children. Wavelet transforms were applied to the traces in an attempt to separate the two groups. RESULTS: 20 traces were obtained from unwell children and 12 from controls. Analysis of the entropy of the wavelet transform of the photoplethysmogram allows the differentiation of unwell children from controls (p = 0.00002). CONCLUSIONS: Wavelet transform of the photoplethysmogram offers the possibility of a rapid non-invasive method of screening children for significant illness.

Fracture of the sternum in children.

OBJECTIVE: Sternal fracture is poorly characterised in children. The purpose of this study was to gain insight into the mechanism, radiological characteristics, and accompanying injuries of sternal fracture in children. METHODS: The study was retrospective. The records of all children who underwent plain radiography of the sternum, or computed tomography of the thorax after trauma, over a 40 month period in our paediatric hospital were reviewed for evidence of sternal fracture. RESULTS: 12 of 33 children identified had radiological evidence of sternal fracture. The age range of children with fractures was 5 to 12 years. Eleven children had fracture of the anterior cortex of the first or second sternebra of the body of the sternum. One child had fracture through the manubriosternal joint with posterior displacement of the body. Seven fractures resulted from direct blows to the anterior chest, five fractures resulted from hyperflexion injury of the thoracic spine. None were the result of motor vehicle crash. All fractures were isolated injuries. CONCLUSIONS: Sternal fracture is uncommon in children. Injury may result from direct or indirect violence. The child's sternum is commonly fractured by more minor blunt trauma than generally recognised in the literature. All patients with sternal fracture after indirect violence should have careful examination of the spine. Patients with undisplaced anterior cortical fracture without other injury may be safely discharged from the emergency department.

Standard pulse oximeters can be used to monitor respiratory rate.

BACKGROUND: One of the most important limitations of standard pulse oximeters is the inability to detect changes in respiratory rate until oxygenation is affected. This study sought to determine if analysis of the plethysmogram by wavelet transforms would enable the determination of changes in respiratory rate at an earlier stage. METHODS: Ten healthy adult volunteers were monitored, breathing at baseline and predetermined respiratory rates, using a standard pulse oximeter. Photo-plethysmograms captured in an attached lap top computer were then analysed using wavelet transforms. RESULTS: Determination of baseline respiratory rate and subsequent changes including apnoea were easily identified. COMMENT: Wavelet transforms permit the accurate determination of respiratory rate by a standard pulse oximeter.