CT brain interpretation in paediatric trauma.

The management of head trauma is an essential component of working in Emergency Medicine, be it a paediatric, adult or mixed emergency department. Between 33% and 50% of the 1.4 million people who attend UK emergency departments (ED) annually with a head injury are children. Patient outcomes in this cohort are strongly associated with rapid identification and treatment of intracranial pathology. The management of pathologies such as expanding intracranial haemorrhage and raised intracranial pressure requires urgent medical and neurosurgical treatment. This is facilitated by rapid interpretation of CT brain images in the ED. In this paper, we discuss the approach to interpretation of a CT brain following a traumatic head injury. While this is not a substitute for a formal radiologist report, being able to identify significant abnormalities may help you, as the treating clinician, to identify and manage any acute life threats; engage and potentiate discussion with your neurosurgical team and expedite the potential transfer and treatment of your patient.

Fifteen-minute consultation: Management of paediatric minor burns.

Burn injuries are a common presentation to the paediatric emergency department (PED) and are painful, distressing and may have long-term sequelae. In adhering to the first aid principles of burns management, we aim to alleviate pain, prevent bacterial contamination and minimise the extent of injury. First aid involves cooling the burn and covering with an appropriate material while simultaneously providing analgesia. Assessing the severity (depth and total body surface area) of the burn are important for prognostication with implications for management. It is imperative to consider non-accidental injury in burns, which be present in 10% of cases .

Fifteen-minute consultation: A guide to the paediatric primary survey.

It's 21:00 and you receive a stand-by call from the local ambulance service. Peter, a 9-year-old boy, was riding an electric scooter and has collided with a car. He has reduced consciousness, signs of shock and is hypoxic. How will you prepare your team? What are the possible injuries? Who will perform the primary survey? Injury is the leading cause of morbidity and mortality in the paediatric population accounting for approximately half of all attendances to paediatric emergency departments in the UK and Ireland. Major trauma can be distressing for patients, parents and physicians. Managing major trauma is challenging and it is vital to have a clear and organised approach. In this 15-minute guide we describe a structured approach to the primary survey that includes how to prepare before the child's arrival, the suggested roles of team members and the key components of the primary survey. We discuss life-threatening injuries, the life-saving bundle and the principles of resuscitation, and the role of imaging in the initial assessment of the injured child.

Secondary survey in paediatric trauma.

The purpose of a secondary survey is to identify the non-life-threatening injuries that are not a priority in the primary survey, but if missed could have long-term impacts for the patient. This article provides a structured approach of the head-to-toe examination required for the secondary survey. We follow the journey of a 9-year-old boy, Peter, who was involved in an accident-electric scooter versus car. After resuscitation and primary survey, you have been asked to carry out the secondary survey. This is a guide of the steps to follow in order to carry out a comprehensive examination to ensure nothing is missed. It highlights the importance of good communication and documentation.

Fifteen-minute consultation: Bruising in the premobile child.

A bruise in a premobile infant is an uncommon finding and often results in referral to the paediatric or emergency departments, acknowledging the potential for physical abuse in this vulnerable cohort. Our role as clinicians is to undertake a thorough assessment, consider potential differentials and organise appropriate investigations, with involvement of the wider multidisciplinary team. In this article, we use a case vignette to discuss how one would approach a bruise in the premobile infant including the evidence base.

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.

Mortality in adolescent trauma: a comparison of children's, mixed and adult major trauma centres.

OBJECTIVE: We aimed to compare adolescent mortality rates between different types of major trauma centre (MTC or level 1; adult, children's and mixed). METHODS: Data were obtained from TARN (Trauma Audit Research Network) from English sites over a 6-year period (2012-2018), with adolescence defined as 10-24.99 years. Results are presented using descriptive statistics. Patient characteristics were compared using the Kruskal-Wallis test with Dunn's post-hoc analysis for pairwise comparison and χ2 test for categorical variables. RESULTS: 21 033 cases met inclusion criteria. Trauma-related 30-day crude mortality rates by MTC type were 2.5% (children's), 4.4% (mixed) and 4.9% (adult). Logistic regression accounting for injury severity, mechanism of injury, physiological parameters and 'hospital ID', resulted in adjusted odds of mortality of 2.41 (95% CI 1.31 to 4.43; p=0.005) and 1.85 (95% CI 1.03 to 3.35; p=0.041) in adult and mixed MTCs, respectively when compared with children's MTCs. In three subgroup analyses the same trend was noted. In adolescents aged 14-17.99 years old, those managed in a children's MTC had the lowest mortality rate at 2.5%, compared with 4.9% in adult MTCs and 4.4% in mixed MTCs (no statistical difference between children's and mixed). In cases of major trauma (Injury Severity Score >15) the adjusted odds of mortality were also greater in the mixed and adult MTC groups when compared with the children's MTC. Median length of stay (LoS) and intensive care unit LoS were comparable for all MTC types. Patients managed in children's MTCs were less likely to have a CT scan (46.2% vs 62.8% mixed vs 64% adult). CONCLUSIONS: Children's MTC have lower crude and adjusted 30-day mortality rates for adolescent trauma. Further research is required in this field to identify the factors that may have influenced these findings.

Bridging the Gap: Using Interspecialty High-Fidelity Simulation to Improve Skills in Adolescent Emergency Medicine.

INTRODUCTION: Adolescents are attending emergency departments (EDs) in increasing numbers, accounting for 21% attendances in the United Kingdom. A recent report by the Northern Ireland Commissioner for Children and Young People highlighted deficiencies in the support offered by EDs to adolescents. AIM: The aim of this study was to develop a high-fidelity simulation-based course focused on managing common adolescent presentations to the ED. METHODOLOGY: A 1-day mixed-modality course comprising of simulations, lectures, and skill stations, mapped to the pediatric and emergency medicine curriculum, was designed. The faculty developed and delivered 8 high-fidelity simulations. Precourse and immediate postcourse questionnaires were used to assess confidence levels and gain qualitative data. Delayed feedback was collected at 3 months. RESULTS: There were 36 participants; 86% (n = 31) completed the precourse feedback, 96% (n = 34) completed the postcourse feedback, and 47% (n = 17) completed the delayed feedback. There was a statistically significant increase in self-reported confidence across all domains with a median increase of 21.25% immediately, sustained at 20% on delayed 3-month feedback. Qualitative feedback noted a change in practice, "I used (the knowledge) regularly while working in children's A + E." CONCLUSIONS: This was a feasible, high-fidelity simulation-based study day covering the key components of adolescent medicine. The sustained increase in confidence at 3 months and the positive qualitative and quantitative feedback are supportive of the use of simulation to improve adolescent emergency care.

Lazarus Syndrome - Challenges Created by Pediatric Autoresuscitation.

ABSTRACT: Pediatric autoresuscitation is extremely rare, with only 4 documented cases in the literature. The longest recorded time between stopping cardio pulmonary resuscitation (CPR) and return of spontaneous circulation is 2 minutes. We report a previously well 18-month-old who attended the emergency department after an unexplained cardiac arrest. After 10 cycles of CPR, resuscitation was stopped; 6 minutes later, the patient had a return of spontaneous circulation and was transferred to the pediatric intensive care unit. The patient remains alive but with significant neurological impairment. There are a variety of theories regarding the pathology of pediatric autoresuscitation. The most commonly accepted model is that there is a degree of autopositive end-expiratory pressure impending venous return as a consequence of vigorous ventilation during CPR. This case challenges clinicians to reassess our current definition of death and reaffirms the need for clearer guidelines surrounding the certification of death.

Burns and Scalds Assessment Template: standardising clinical assessment of childhood burns in the emergency department.

OBJECTIVES: The Burns and Scalds Assessment Template (BaSAT) is an evidence-based proforma coproduced by researchers and ED staff with the aim of (1) standardising the assessment of children attending ED with a burn, (2) improving documentation and (3) screening for child maltreatment. This study aimed to test whether the BaSAT improved documentation of clinical, contributory and causal factors of children's burns. METHODS: A retrospective before-and-after study compared the extent to which information was recorded for 37 data fields after the BaSAT was introduced in one paediatric ED. Pre-BaSAT, a convenience sample of 50 patient records of children who had a burn was obtained from the hospital electronic database of 2007. The post-BaSAT sample included 50 randomly selected case notes from 2016/2017 that were part of another research project. Fisher's exact test and Mann-Whitney U tests were conducted to test for statistical significance. RESULTS: Pre-BaSAT, documentation of key data fields was poor. Post-BaSAT, this varied less between patients, and median completeness significantly (p<0.001) increased from 44% (IQR 4%-94%) to 96% (IQR 94%-100%). Information on 'screening for maltreatment, referrals to social care and outcome' was poorly recorded pre-BaSAT (median of 4% completed fields) and showed the greatest overall improvement (to 95%, p<0.001). Documentation of domestic violence at home and child's ethnicity improved significantly (p<0.001) post-BaSAT; however, these were still not recorded in 36% and 56% of cases, respectively. CONCLUSION: Introduction of the BaSAT significantly improved and standardised the key clinical data routinely recorded for children attending ED with a burn.

Epidemiology of adolescent trauma in England: a review of TARN data 2008-2017.

OBJECTIVES: Trauma contributes significantly to adolescent morbidity and mortality. We aimed to ascertain the epidemiology of adolescent trauma to inform prevention strategies. METHODS: Data were abstracted from TARN (Trauma Audit Research Network) from English sites over a 10-year period (2008-2017). Adolescents were defined as 10-24 completed years. Descriptive statistical analysis was used in this study. RESULTS: There were 40 680 recorded cases of adolescent trauma. The majority were male (77.3%) and aged 16-24 years old (80.5%). There was a 2.6-fold increase during the study time frame (p<0.0001) in the total annual number of cases reported to TARN. To account for increasing hospital participation, the unit trauma cases per hospital per year was used, noting an increasing trend (p=0.048). Road traffic collision (RTC) was the leading cause of adolescent trauma (50.3%). Pedestrians (41.2%) and cyclists (32.6%) were more prevalent in the 10-15 year group, while drivers (22.9%) and passengers (17.8%) predominated in the 16-24 year group. Intentional injury was reported in 20.7% (alleged assault in 17.2% and suspected self-harm in 3.5%). This was more prevalent in the 16-24 year group. The proportion of trauma reported due to violence has increased with stabbings increasing from 6.9% in 2008 to 10.2% in 2017 (p<0.0001). Evidence of alcohol or drug use was recorded in 20.1% of cases. There was an increase in the number treated in major trauma centres (45.7% 2008 vs 63.5% 2017, p<0.0001). Trauma was more likely to occur between 08:00 and 00:00, at weekends and between April and October. Overall mortality rate was 4.1%. Those with a known psychiatric diagnosis had a higher mortality (6.3% vs 4.4%, p<0.001). CONCLUSIONS: RTCs and intentional injuries are leading aetiologies. Healthcare professionals and policy-makers need to prioritise national preventative public health measures and early interventions to reduce the incidence of trauma in this vulnerable age group.

Fifteen-minute consultation: How to be the paediatrician at a trauma call.

The management of paediatric trauma patients can be complex, involving a coordinated multidisciplinary approach. Paediatricians form an integral part of the trauma team and are often tasked with managing circulation. In this article, we will discuss the assessment of catastrophic haemorrhage and 'circulation' through the viewpoint of a paediatrician via a case discussion. This will include initial investigations and management, noting the time critical nature in identifying and stopping catastrophic haemorrhage. The discussion will comment on how to address hypovolaemic shock and touch on the role of imaging.

Fifteen-minute consultation: Childhood burns: inflicted, neglect or accidental.

Burns are a relatively common injury in children accounting for over 50 000 emergency department attendances each year. An estimated 1 in 10 of these are due to maltreatment. These may present in the form of physical abuse or neglect with a reported ratio of 1:9. A burn associated with maltreatment may be a marker for future abuse or neglect and it is paramount that concerns are identified and addressed at the initial visit. Paediatricians need to be confident to identify safeguarding concerns specific to childhood burns and investigate accordingly. In this review, key variables that may aid in differentiating maltreatment from accidental burns are discussed in a case-based format, utilising up-to-date evidence to support the recommendations. Despite a proportion of burns resulting from physical abuse, the rate of child protection investigations in these patients are significantly lower than for children who present with other forms of physical injuries despite a similar proportion of positive findings. Our objective is to review the available evidence to support the safe assessment and management of children presenting with scalds or contact burns.

Smartphone use for Paediatric Calculations in Emergencies (SPaCE).

BACKGROUND: The preparation for critically ill children involves calculating drug and fluid volumes using the commonly taught WETFLAG (weight, energy, endotracheal tube, fluids, lorazepam, adrenaline, glucose) acronym. While smartphone applications (apps) are increasingly used for these calculations in clinical practice, limited studies have explored their accuracy and safety. AIM: To assess the accuracy of three calculation methods for paediatric emergency drug doses and fluid volumes: a smartphone app, reference charts and traditional calculation methods. The secondary aims were to investigate the effect on the time taken and self-reported stress levels. METHODS: A convenience sample of healthcare professionals from four hospitals contributed. Participants calculated drug and fluid doses for fictional patients using the three different methods. The method and case order were randomised centrally. The study recorded the number of errors made during the calculations, healthcare professionals' self-reported stress levels on a scale of 0 (no stress) to 10 (maximum stress) and the time taken for each case. The app was developed at the direct request of the study team. RESULTS: Ninety-six participants calculated values for six fictional cases, resulting in 576 calculations. Traditional calculation methods showed a statistically significant higher rate of error compared with the use of a smartphone app or reference charts (mean=1, 0, 0, respectively). The smartphone app outperformed both traditional calculation methods and reference charts for time taken and user-reported stress levels. CONCLUSIONS: Traditional methods of 'WETFLAG' drug and fluid calculations are associated with a statistically significant increased risk of error compared with the use of reference charts or smartphone app. The smartphone app proved significantly faster and less stressful to use compared with traditional calculation methods or reference charts.

Comparison of injury patterns and interventions between adolescent, adult and paediatric trauma cases: a cross-sectional review of TARN data.

OBJECTIVES: The aim is to compare adolescent (10-24.99 years) trauma patterns and interventions to adult (≥25) and paediatric cases (<10) and to identify any transition points. DESIGN AND SETTING: Data were collected from the Trauma and Audit Research Network (TARN) over a 10-year period. We conducted a retrospective cross-sectional analysis. PARTICIPANTS: After exclusions there were 505 162 TARN eligible cases. PRIMARY AND SECONDARY OUTCOME MEASURES: To compare adolescent trauma patterns and interventions to those in paediatric and adult cohorts. Identify transition points for mechanism of injury (MOI) and interventions by individual year over the adolescent age range (10-24.99). RESULTS: Road traffic accidents are the most common MOI in the adolescent group, in contrast to both the paediatric and adult group where falls <2 m are most common. Violence-related injury (shootings and stabbings) are more common in the adolescent group, 9.4% compared with 0.3% and 1.5% in the paediatric and adult groups, respectively. The adolescent grouping had the highest median Injury Severity Score (ISS) and the highest proportion of interventions. The proportion of cases due to stabbing peaked at age 17 (11.8%) becoming the second most common MOI. The median ISS peaked at 13 at age 18. The percentage of cases that fulfil the definition of polytrauma enters double figures (11.8%) at age 15 reaching a peak of 17.6% at age 18. The use of blood products within the first 6 hours remains around 2% (1.6%-2.8%) until age 15 (3.4%), increasing to 4.7% at age 16. CONCLUSIONS: Trauma patterns are more closely aligned between adult and paediatric cohorts than adolescence. The highest proportion of trauma interventions occur in the adolescent population. Analysing the adolescent cohort by year of age identified some common points for when descriptors or outcomes altered in frequency, predominantly between the ages of 15-17 years.

Reducing oral steroid intolerability and drug costs for acute wheezers: A retrospective evaluation of a clinical management algorithm in a Pediatric Emergency Department.

PROJECT AIM: To retrospectively evaluate a clinical management algorithm for acute wheezers in a UK Pediatric Emergency Department (PED). OVERVIEW AND RATIONALE: Acute wheezing attacks are a leading cause of PED attendances and inpatient admissions. Prednisolone, a routine treatment, is intolerable in almost one-third of children, requiring repeated dosing, which may prolong length of stay (LOS). To address this problem, we: (1) developed an acute management algorithm (concise, single-sided flow-chart, instructing immediate management); (2) modified the OCS regime from prednisolone (1 mg/kg, 3-day course) to dexamethasone (600 then 300 mcg/kg); (3) and disseminated guidance regionally. Written information-handouts, e-mails, and posters-were followed-up with verbal reinforcement. We implemented the algorithm in 2017 and revised it further in 2018. EVALUATION: In 2019, we retrospectively collected data on 100 acute wheeze attendances (those requiring OCS, aged 2-14), between October and December in 2016, 2017, and 2018 (n = 300), and assessed outcomes. RESULTS: Over a 48-month period, we reduced OCS intolerability by 67.2% and OCS drug costs by 85.8% (saving £41,470.14), while not significantly influencing the other outcomes. CONCLUSIONS: Reduced intolerability and substantial cost savings can be achieved by implementing a structured acute pediatric wheeze algorithm and modifying the OCS to single-dose dexamethasone (300 mcg/kg).

Exposure and attitudes to adolescent health amongst Paediatric trainees in Northern Ireland: a mixed-methods study.

AIMS: To determine the exposure and attitudes of paediatric trainees towards adolescent medicine. METHODS: All paediatric trainees in the Northern Ireland deanery (n=107) were invited to participate in an online survey in March 2016. The questionnaire was based on the 'Modified Perceptions of Adolescent Issues and Resources: Care of Adolescents' questionnaire. The questions included a 5-point Likert scale (1-strongly disagree, 5-strongly agree) as well as open questions. All paediatric trainees were invited to attend focus groups to expand on themes generated from the questionnaire. RESULTS: The response rate for the paediatric survey was 62% (n=66). Trainees identified adolescence as an area of importance similar to paediatrics and neonates; however, knowledge, confidence, skills and previous teaching in adolescent medicine were lower than for neonatal medicine and general paediatrics. Trainees who saw ≥6 adolescent patients per week were more likely to rate the importance of adolescent medicine higher. Trainees' perceived confidence, knowledge, self-rated skills and prior teaching in adolescent medicine were strongly correlated. Most (70%) respondents stated that they had not attended an adolescent transition clinic during their postgraduate training. Undergraduate and postgraduate teaching for adolescent health was rated poorly. CONCLUSIONS: This project identified a paediatric trainee population that are aware of the importance of adolescent health but with low perceived knowledge, skills and confidence to manage them. Education is required to enhance learning and improve outcomes for adolescent patients.

First aid for children's burns in the US and UK: An urgent call to establish and promote international standards.

INTRODUCTION: Appropriate first aid can reduce the morbidity of burns, however, there are considerable variations between international first aid recommendations. We aim to identify, and compare first aid practices in children who present to Emergency Departments (ED) with a burn. METHODS: A prospective cross-sectional study of 500 children (0-16 completed years) presenting with a burn to a paediatric ED in the UK (Cardiff) and the USA (Denver, Colorado), during 2015-2017. The proportion of children who had received some form of first aid and the quality of first aid were compared between cities. RESULTS: Children attending hospital with a burn in Cardiff were 1.47 times more likely (RR 1.47; CI 1.36, 1.58), to have had some form of first aid than those in Denver. Denver patients were 4.7 time more likely to use a dressing and twice as likely to apply ointment/gel/aloe vera than the Cardiff cohort. First aid consistent with local recommendations was only administered to 26% (128/500) of children in Cardiff and 6% (31/500) in Denver. Potentially harmful first aid e.g. application of food, oil, toothpaste, shampoo or ice was applied to 5% of children in Cardiff and 10% in Denver. CONCLUSION: A low number of children received optimal burns first aid, with potentially harmful methods applied in a considerable proportion of cases. There is an urgent need for internationally agreed, evidence-based burn first aid recommendations.