In Noggin-cast part 2, we explore the relevant literature with regard to investigating headaches in children.  No magic answers yet, but we discovered a few useful tips along the way… and found a handful of references you can impress your colleagues with.

When faced with a worried family, we all would like to offer the appropriate reassurance, or do the appropriate test – without being too blase or too anxious.  Headaches, in particular, are important because the tests are usually not required, and are either unavailable or potentially harmful.  And if you miss a brain tumour… well, no-one wants that to happen.

Headache evidence-base PEMcast – Outline

Most papers address the same question: are there any clinical features distinguishing the benign from serious causes of headaches?

Kate has picked 2 review papers that have larger numbers of patients, and another 2 which discuss investigating headaches in the Emergency Department.  They’re all pretty short and the abstracts give a reasonable overview…

[cp] Welcome, disclaimer, introductions.

[KB] Conicella 2008 – Intense pain vs moderate, occipital location

[cp] Lewis 2000 – Occipital location, unable to describe / localise

PAWER:

• Papilloedema
• Ataxia
• Weakness
• Eye movements
• Reflexes

[WH] Kan 2000 – high CT rate, low analgesia rate

[cp] Lateef 2009 – CT appropriate for life-threatening conditions requiring urgent intervention, radiation risk (see XRayRisk.com)

[all] Conclusions, goodbye

References

Conicella E, Raucci U, Vanacore N, Vigevano F, Reale A, Pirozzi N, Valeriani M.
The child with headache in a pediatric emergency department.
Headache. 2008 Jul;48(7):1005-11.
PubMed PMID: 18705026.

Lewis DW, Qureshi F.
Acute headache in children and adolescents presenting to the emergency department.
Headache. 2000 Mar;40(3):200-3.
PubMed PMID: 10759922.

Kan L, Nagelberg J, Maytal J.
Headaches in a pediatric emergency department: etiology, imaging, and treatment.
Headache. 2000 Jan;40(1):25-9.
PubMed PMID: 10759899.

Lateef TM, Grewal M, McClintock W, Chamberlain J, Kaulas H, Nelson KB.
Headache in young children in the emergency department: use of computed tomography.
Pediatrics. 2009 Jul;124(1):e12-7. doi: 10.1542/peds.2008-3150.
PubMed PMID: 19564257.

Pediatric Emergency Departments see a few children a day with headache. So how do we pick out the serious ones?

In this “noggin-cast” we explore the causes of headache, including Primary headache like migraine and tension headache, secondary headaches from viral illness, and a few other strange ones…

Outline: Headache PEMcast

Intro, disclaimer and Welcome: CP

Headache intro: KB – why we care/worry

Headache incidence/prevalence: KB

Headache Classification – International Headache Society: http://ihs-classification.org/en/

The Primary Headaches: CP

• Migraine

• Tension

• Cluster

The Secondary Headaches: WH

• Benign eg Viral illness/sinusitis – most common in children

• Pathological eg SOL, Meningitis, BIIH

Cranial neuralgias, Facial pain and other headaches: KB

• Optic neuritis
• Shingles
• Weird and wonderful causes!

Headache History – important points KB

Headache Examination – important features WH

“PAWER”: Papilloedema Ataxia Weakness Eyes Reflexes

Headache Investigation – CP

Follow up – CP

It seems that this one slipped under the radar, when we originally published it… Because I followed it with a tongue-in-cheek summary post about the (lack of) utility of tests for appendicitis, and did not leave enough of a gap between the two posts, iTunes only picked up the abbreviated jokey version, leaving the original PEMcast undiscovered by many…

So here it is again, for the benefit of our loyal followers on iTunes.
The original post, which is surprisingly similar, can be found here:
http://empem.org/2011/02/appendicitis-improving-diagnostic-accuracy/

Outline: Tests for Appendicitis

[CP] hello, disclaimer, introduction

Review Article:

Bundy 2007 JAMA “Does this child have appendicitis?”
[CP] overview (including methods)

[KB] appendicitis symptoms

[SF] appendicitis signs

[CP] results: symptoms

[KB] results: signs

[SF] results: WBC count & differential

[CP] results: CRP & ESR

[ALL] comments re blood tests especially WBC

Passing mention of O’Shea 1988 Pediatric Emergency Care

[CP] Scoring systems: Alvarado Score (still with reference to Bundy)

[CP] Alvarado 1986 Annals of Emergency Medicine

[SF] Scoring systems: (Samuel) Paediatric Appendicitis Score (still with reference to Bundy)

[SF] Samuel 2002 J Pediatric Surgery

[KB] Scoring systems: Low-Risk decision rule: (with reference to Bundy)

[KB] Kharbanda 2005 Pediatrics

Passing mention of Schneider 2007 (Annals of Emergency Medicine) prospective evaluation of scoring systems.
(still with reference to Bundy):

[SF] Clinical gestalt (as indicated by imaging ordered)

[CP] Comparison with Adult data

[KB] Limitations in the Literature

Imaging Tests for suspected appendicitis

[CP] introduction (rule-out vs rule-in strategies, unnecessary when diagnosis obviously appendicitis or obviously not)

[KB] UltraSound with Graded Compression – Sim 1989 J National Med Association

[SF] CT for Appendicitis: Callahan 2002 Radiology

[CP] Contrast or not: Kaiser 2004 Radiology

[SF] An Argument for Ultrasound: Strouse 2010 Radiology

[KB] Routine Ultrasound & Limited CT: Toorenvliet 2010 World J Surgery

[ALL] Comments re: Imaging in suspected appendicitis
(where does Australia sit on the UK – USA spectrum – U/S vs CT?)

What’s new?

[SF] calprotectin (S100A8/A9): Bealer & Colgin 2010 Academic Emergency Medicine – featured in Journal Watch top 10 most read articles in EM in 2010

Bottom Line

[KB] Acheson & Banerjee 2010 Arch Dis Child Education & Practice Edition

[ALL] When to do blood tests?

[ALL] When to get imaging?

[ALL] When to get Surgical review?

[ALL] Discharge advice – when appendicitis unlikely but not excluded

[CP] Summary, goodbye

References

Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE.
Does this child have appendicitis?
JAMA. 2007 Jul 25;298(4):438-51. Review.
PubMed PMID: 17652298; PubMed Central PMCID: PMC2703737.

O’Shea JS, Bishop ME, Alario AJ, Cooper JM.
Diagnosing appendicitis in children with acute abdominal pain.
Pediatr Emerg Care. 1988 Sep;4(3):172-6.
PubMed PMID: 3186519.

Alvarado A.
A practical score for the early diagnosis of acute appendicitis.
Ann Emerg Med. 1986 May;15(5):557-64.
PubMed PMID: 3963537.

Samuel M.
Pediatric appendicitis score.
J Pediatr Surg. 2002 Jun;37(6):877-81.
PubMed PMID: 12037754.

Kharbanda AB, Taylor GA, Fishman SJ, Bachur RG.
A clinical decision rule to identify children at low risk for appendicitis.
Pediatrics. 2005 Sep;116(3):709-16.
PubMed PMID: 16140712.

Schneider C, Kharbanda A, Bachur R.
Evaluating appendicitis scoring systems using a prospective pediatric cohort.
Ann Emerg Med. 2007 Jun;49(6):778-84, 784.e1. Epub 2007 Mar 26.
PubMed PMID: 17383771.

Sim KT, Picone S, Crade M, Sweeney JP.
Ultrasound with graded compression in the evaluation of acute appendicitis.
J Natl Med Assoc. 1989 Sep;81(9):954-7. Review.
PubMed PMID: 2674464; PubMed Central PMCID: PMC2626073.

Callahan MJ, Rodriguez DP, Taylor GA.
CT of appendicitis in children.
Radiology. 2002 Aug;224(2):325-32.
PubMed PMID: 12147823.

Kaiser S, Finnbogason T, Jorulf HK, Söderman E, Frenckner B.
Suspected appendicitis in children: diagnosis with contrast-enhanced versus nonenhanced Helical CT.
Radiology. 2004 May;231(2):427-33. Epub 2004 Mar 18.
PubMed PMID: 15031433.

Strouse PJ.
Pediatric appendicitis: an argument for US.
Radiology. 2010 Apr;255(1):8-13. doi: 10.1148/radiol.10091198.
PubMed PMID: 20308438.

Toorenvliet BR, Wiersma F, Bakker RF, Merkus JW, Breslau PJ, Hamming JF.
Routine ultrasound and limited computed tomography for the diagnosis of acute appendicitis.
World J Surg. 2010 Oct;34(10):2278-85. doi: 10.1007/s00268-010-0694-y.
PubMed PMID: 20582544; PubMed Central PMCID: PMC2936677.

Bealer JF, Colgin M.
S100A8/A9: a potential new diagnostic aid for acute appendicitis.
Acad Emerg Med. 2010 Mar;17(3):333-6. doi: 10.1111/j.1553-2712.2010.00663.x.
PubMed PMID: 20370768.

Acheson J, Banerjee J.
Management of suspected appendicitis in children.
Arch Dis Child Educ Pract Ed. 2010 Feb;95(1):9-13. doi: 10.1136/adc.2009.168468.
PubMed PMID: 20145013.

Pediatric Emergency Medicine is an interesting sport. Really very broad, and really quite narrow too! There are a handful of presenting complaints that keep us busy most of the time, the same few recurring clinical scenarios – narrow. And then there is everything else, a happy hunting ground for generalists, with loads of undifferentiated problems – broad.

I recently prepared a little talk for SMACC 2013, the inaugural Social Media and Critical Care Conference to be held in Sydney, and worldwide via the awesome power of modern technology. The challenge was to fit the Pecha Kucha format: 20 slides, average 20 seconds per slide… so I ‘dumbed down’ Paediatric Emergency Medicine as much as I could.

Please be aware that this talk applies to First-World Emergency Departments, and assumes a reasonable level of clinical experience with acute paediatrics. Don’t be freaked out by my sweeping generalisations, and remember that our disclaimer still applies.

Video embed courtesy of GMEP

(alternative link)

See more PK-talks over at the SMACC 2013 website or check out the SMACC vimeo channel.

Send us a comment or tweet… let’s chat.

Cheers

Colin

Just a quick post to say Thank You to all our followers.  Your quiet enthusiasm inspires us!

We have just over 50 PEMcasts on EMPEM.org now, and our total downloads of mp3 podcasts has recently crossed the 100,000 mark.

We aim to keep them coming, so send us a comment to let us know what you’d like us to cover next…  Help us reach 1 million downloads!

Thanks for your support.

Cheers

Colin & pals

So, you thought it was straightforward: suspect UTI, diagnose UTI, treat UTI…
And let someone else worry about the follow-up.
Unfortunately, we work in a fragmented system, where we need to kick-start the correct follow-up for our patients, who may otherwise miss out if we don’t get them on the right track before they leave the Emergency Department.

We used to be paranoid about investigating Urinary Tract Infection in children.  Some of us still are, some of us are less worried, while some of us have not yet realised that kids are different, and are unaware that the Pediatricians out there have been aggressively investigating UTIs in kids for decades.  Maybe we can stop trying to educate and inform these laggards now?

Although the evidence is far from complete, the landscape of pediatric UTI is definitely changing, and the discussion is driving a less aggressive approach to investigating and following up UTI in children.  But are we swinging too far in the other direction?

Join us on a tour of the literature, and decide for yourself…

UTI Controversies PEMcast – Outline

[cp] Hello, disclaimer, introduction

[cp] Background

Common clinical problem, significant consequences if missed – some debate about this more recently.
Not clear what pre-requisites are for renal scarring – whether genetic predisposition, related to timing of infection and treatment, severity of infection.
Not clear whether renal scarring is preventable by a strategy of aggressive treatment and investigation.
Both the treatments and investigations come with associated risks, discomfort, and costs.

[AH] Controversies include:

• When to treat with IV ABs
• How long to treat
• When to give prophylactic antimicrobials
• Utility of proof-of-cure urine test
• Who to investigate
• How to investigate
• Treatment of VUR

…because of a relative lack of RCT evidence.

[cp] Ideally we need to balance risks and costs of any tests/interventions against the likelihood of benefit to the patient, aiming to achieve ‘greatest good for the greatest number’ with our resources (or: spend more money to prevent any adverse outcomes).

We will not be able to definitively answer these questions, but aim to give a representative cross-section of opinion and a small amount of science to inform the debate…

Papers

[AH] NICE CG 54 (2007) (& RCH Melbourne interpretation)

http://www.nice.org.uk/CG54

http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=5241
http://www.rch.org.au/clinicalguide/cpg.cfm?doc_id=15338

[SF] Coulthard 2008 (scarring)
http://www.ncbi.nlm.nih.gov/pubmed/19015216

[SF] Montini 2008 (Italian mob – prophylaxis RCT)
http://www.ncbi.nlm.nih.gov/pubmed/18977988

[AH] Craig 2009 NEJM (prophylaxis)
http://www.ncbi.nlm.nih.gov/pubmed/19864673

[cp] Mathews 2009 (VUR controversies)
http://www.ncbi.nlm.nih.gov/pubmed/19570724

[cp] Schroeder 2011 (validation of NICE)
http://www.ncbi.nlm.nih.gov/pubmed/22065183

[cp] Finnell 2011 (AAP Guideline, incorporating info from Montini & Craig):
Background:
http://www.ncbi.nlm.nih.gov/pubmed/21873694
Guideline:
http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330.full.pdf+html

[SF] Tullus 2012 (Editorial, AAP vs NICE)
http://www.ncbi.nlm.nih.gov/pubmed/22203365

[all] Summary & best-guess recommendations

References

National Institute for Health and Clinical Excellence
Clinical Guideline CG 54: Urinary Tract Infection in Children
August 2007 http://www.nice.org.uk/CG54

Coulthard MG, Lambert HJ, Keir MJ.
Do systemic symptoms predict the risk of kidney scarring after urinary tract infection?
Arch Dis Child. 2009 Apr;94(4):278-81. doi: 10.1136/adc.2007.132290. Epub 2008 Nov 17. PubMed PMID: 19015216.

Montini G, Rigon L, Zucchetta P, Fregonese F, Toffolo A, Gobber D, Cecchin D, Pavanello L, Molinari PP, Maschio F, Zanchetta S, Cassar W, Casadio L, Crivellaro C, Fortunati P, Corsini A, Calderan A, Comacchio S, Tommasi L, Hewitt IK, Da Dalt L, Zacchello G, Dall’Amico R; IRIS Group.
Prophylaxis after first febrile urinary tract infection in children? A multicenter, randomized, controlled, noninferiority trial.
Pediatrics. 2008 Nov;122(5):1064-71. doi: 10.1542/peds.2007-3770. PubMed PMID: 18977988.

Craig JC, Simpson JM, Williams GJ, Lowe A, Reynolds GJ, McTaggart SJ, Hodson EM, Carapetis JR, Cranswick NE, Smith G, Irwig LM, Caldwell PH, Hamilton S, Roy LP; Prevention of Recurrent Urinary Tract Infection in Children with Vesicoureteric Reflux and Normal Renal Tracts (PRIVENT) Investigators.
Antibiotic prophylaxis and recurrent urinary tract infection in children.
N Engl J Med. 2009 Oct 29;361(18):1748-59. doi: 10.1056/NEJMoa0902295.
Erratum in: N Engl J Med. 2010 Apr 1;362(13):1250. PubMed PMID: 19864673.

Mathews R, Carpenter M, Chesney R, Hoberman A, Keren R, Mattoo T, Moxey-Mims M, Nyberg L, Greenfield S. Controversies in the management of vesicoureteral reflux: the rationale for the RIVUR study.
J Pediatr Urol. 2009 Oct;5(5):336-41. doi: 10.1016/j.jpurol.2009.05.010. Epub 2009 Jul 1. Review. PubMed PMID:
19570724; PubMed Central PMCID: PMC3163089.

Schroeder AR, Abidari JM, Kirpekar R, Hamilton JR, Kang YS, Tran V, Harris SJ.
Impact of a more restrictive approach to urinary tract imaging after febrile urinary tract infection.
Arch Pediatr Adolesc Med. 2011 Nov;165(11):1027-32. doi: 10.1001/archpediatrics.2011.178. PubMed PMID: 22065183.

Finnell SM, Carroll AE, Downs SM; Subcommittee on Urinary Tract Infection.
Technical report—Diagnosis and management of an initial UTI in febrile infants and young children.
Pediatrics. 2011 Sep;128(3):e749-70. doi: 10.1542/peds.2011-1332. Epub 2011 Aug 28. PubMed PMID: 21873694.

Subcommittee on Urinary Tract Infection and Steering Committee on Quality Improvement and Management.
Urinary Tract Infection: Clinical Practice Guideline for the Diagnosis and Management of the Initial UTI in Febrile Infants and Children 2 to 24 Months.
Pediatrics peds.2011-1330; published ahead of print August 28, 2011, doi:10.1542/peds.2011-1330
http://pediatrics.aappublications.org/content/early/2011/08/24/peds.2011-1330.full.pdf+html

Tullus K.
What do the latest guidelines tell us about UTIs in children under 2 years of age.
Pediatr Nephrol. 2012 Apr;27(4):509-11. doi: 10.1007/s00467-011-2077-5. Epub 2011 Dec 28. PubMed PMID: 22203365.

Urinary Tract Infections in kids are a recurring clinical question that bugs us as clinicians… Why is Urinary Tract Infection in children different from cystitis or pyelonephritis in adults? How hard should we be looking for UTI, and what’s the best way to confirm or exclude the diagnosis?

In this podcast we discuss the diagnosis, important differentials, and treatment of pediatric Urinary Tract Infection.

UTI PEMcast outline

[cp] Hello, disclaimer, introduction

[cp] Background

Common clinical problem, esp in FWS – urinalysis = most useful test

Significant consequences if missed

Controversies for discussion next episode (incl when to treat with IV Antibiotics, how long to treat, when to give prophylactic antimicrobials, proof-of-cure urine test, who to investigate, how to investigate, treatment of VUR)

[AH] Epidemiology (frequency in different age groups & genders, number of admissions) – approx 5% of FWS patients.

[SF] Aetiology (bacteria commonly involved) esp GI organisms – E coli, Klebsiella, Proteus, enterobacter, etc. Pseudomonas = more worrying.

Fastidious organisms eg mycobacteria
STIs (Chlamydia, gonorrhea)

[cp] Concepts / Definitions of:

UTI

Culture-proven vs presumed vs stricter definition (2 out of 3 cultures single-growth)

Cystitis vs pyelonephritis

Asymptomatic bacteriuria

Sterile pyuria

[AH] History

Fever (may frequently be the only symptom)

Dysuria, Frequency, Urgency (in toddlers and older kids)

Systemic upset

Vomiting

Neonates may have hypothermia; loose stools, vomiting, or just NQR

Background info (past medical history etc)

Recent antibiotic use

Shaikh et al JAMA 2007

[SF] Examination

General: well or sick, or Not Quite Right

Hydration, vital signs, fever (attention to measuring method)

Systems – alternative source of fever esp ENT, RS

Abdomen – tenderness (suprapubic / renal angle / RIF)

Perineum & genitalia (local inflammation)

Investigations

[cp] Bedside:

Glucose (DEFG)

Urine:

Collection methods (SPA, in-out catheter, clean-catch, pads (special ones), bag (never))

Cleaning for collection (thorough)

Urine clarity / colour / smell not reliable to exclude/confirm infection!

[AH] Urinalysis: limited sensitivity in under 12 months (leukocyte esterase test, bladder dwell time) – need urgent urine microscopy

Specificity <100% but combination of nitrite & leuks highly suggestive

Do not treat without sampling urine first!

[AH] Urine microscopy: helpful

>100 WBCs/hpf diagnostic (<20 normal), 20-100 less clear

(infants may have UTI without mounting WBC response in urine or blood initially)

RBCs often increased

Bacteria on microscopy – significant esp if all same type (gram-negative rods); mixed = usually contaminant

Epithelial cells >20 suggests contaminated sample

[SF] Urine Culture: Pure growth of single organism is diagnostic if > 100, 000 (10^5) / mL

Mixed growth usually contaminant, but in young infants, check whether one strain predominates (eg mostly E coli with few others)

Negative culture after 48 hours excludes UTI for practical purposes

[SF] Urine sensitivities (if positive culture) – target antibiotics more specifically (some antibiotics not tested, eg enterococci in-vitro sensitivity to Trimethoprim not predictive of in-vivo situation)

[cp] Bloods: if young or unwell: Blood Culture, FBC, CRP, U&E, glucose (others depending on clinical scenario)

CSF sampling in neonate as part of septic screen, even if UTI confirmed (E coli UTI -10% have meningitis) (CXR too if indicated?)

Imaging: not in ED (follow-up imaging – see later)

[AH] Differential Diagnosis:

Local inflammation: Vaginosis, vaginitis, balanitis

Urethritis (STIs)

Epididymo-orchitis

Neighbourhood syndrome eg appendicitis

Systemic infection (few WBCs in urine)

*** commonest = Contaminant (esp in diarrhea, bag samples, inadequate cleansing – epithelial cells)

[SF] Treatment:

Supportive care (esp in younger & unwell patients)

Specific treatment: antibiotics – empiric based on local resistance/sensitivity patterns, then specific based on culture sensitivities

[AH] Diposition:

Some controversy, one approach is to admit all systemically unwell patients, and admit all suspected UTIs under 6 months age, for IV antibiotics (?any role for middle road of admitting for observation, treating with oral antibiotics)

Follow-up:

[cp] Traditionally refer all males and all pre-pubertal females for follow-up with a General Pediatrician (they prefer culture-definite patients)

Some hospitals prefer U/S to be done prior to first clinic visit

[SF] Follow-up imaging controversial, may include U/S urinary tract, MCUG (in infants), DMSA scan, MAG-3 scan) All have different role / focus

Timing of U/S – swollen kidneys in first few weeks

[AH] Prophylactic antimicrobials also controversial – follow local policy

[all] Summary, Goodbye

References

Shaikh N, Morone NE, Lopez J, Chianese J, Sangvai S, D’Amico F, Hoberman A, Wald ER.
Does this child have a urinary tract infection?
JAMA. 2007 Dec 26;298(24):2895-904. Review.
PubMed PMID: 18159059.

Fortunately for us, younger kids are less dedicated in their efforts to harm themselves with a variety of poisons… On the other hand, their sneaky inventiveness knows no bounds, when it comes to getting hold of something that they shouldn’t.

The principles of Clinical Toxicology are similar in kids and adults, but there are a few additional aspects to consider. Join us on a sketch of assessment and management of the poisoned child… or the potentially poisoned child.

Paeds Tox PEMcast: Outline

[cp] Welcome, intro, disclaimer
80,000 calls to Australian Poisons Information Centre per year regarding paediatric unintentional exposures

[sf] Pharmacokinetic / Toxicokinetic differences in kids:
Different body composition – affects volume of distribution
Higher metabolic rate
Immature liver enzymes (& not induced by alcohol and other recreational substances)
However same mg/kg toxic effects for most agents
Actual agent involved is probably most important factor
Remember that venomous animals do not respect size of their victim…

[KH] 2 types of poisoning in kids:
Toddlers: exploratory, unaware of risks,
usually spit out pills (unpleasant taste) or only sip / mouthful of liquid agent
Teenagers: deliberate self-poisoning, serious intent

[sf] Household exposures – call poisons info centre
Most household exposures non-toxic, including:

• thermometer mercury
• Oral Contraceptive Pill
• cosmetic products
• paint
• matches
• cigarette butts (?nicotine)

[cp] ‘One pill can kill’ list:
Airway & Breathing (CNS, RS, muscles):
opiates
paraquat

Circulation (CVS):
calcium channel blockers (SR)
propranolol
dextropropoxyphene
TCAs

Disability (CNS):
(hydroxy) chloroquine
theophylline
organophosphate & carbamate insecticides
hydrcarbons (solvents, eucalyptus oil, kerosene)
camphor

Metabolic / other:
amphetamines
sulphonylureas
naphthalene

[KH] Agents NOT on this list (but can still cause toxicity in sufficient dose):

• paracetamol
• iron
• colchicine
• anticoagulant rat poison

[sf] Adolescent Deliberate Self-Poisoning
Intent vs lethality (not always congruent)
Common agents – OTC medications (Paracetamol), own meds, Parents meds (FHx of psychiatric illness, nature & nurture)

[cp] Acute Management template: “R RSI DEAD”
Resuscitation:
A, B, C
Sugar, seizures, shivering:
hypoglycaemia 5ml/kg of 10% dextrose
seizures: benzodiazepines
hyperthermia – intubation & paralysis; hypothermia: external warming
(emergency antidotes) eg bicarb for TCA, naloxone for opiates

[KH] Risk assessment:
“ADT CP”
Agent(s)
Dose
Timing
Clinical effects & evolving features
Patient factors (co-morbidities, weight)
Hampered by incomplete history (unwitnessed ingestions/exposure) and different range of medications in children

[sf] Tips for Tox Detectives:
Agent: Include all agents in the house, and at grandparents, other places where child has been; contact GP, pharmacy for parents’ meds; Ambos (counting empty packets), proprietary pharmaceutical product indexes (pill colours, shape, inscriptions)
Dose: assume maximum dose (taken by both/all siblings)
Timing: assume worst-case scenario based on possible earliest & latest times

[cp] Acute Management template: “R RSI DEAD”
Resuscitation
Risk assessment
Supportive care & monitoring
Investigations:

• blood sugar
• ECG
• paracetamol level

[cp/KH both]:
Decontamination (induced emesis, gastric lavage, activated charcoal, whole bowel irrigation)
Enhanced elimination (repeat-dose activated charcoal, dialysis/filtration, urinary alkalinisation – specific agents for each) charcoal heamoperfusion
Antidotes – small role
Disposition (medical and psychosocial)

[sf] Toddler Mystery Pill Ingestion management:
Admit & observe 12 hrs +
Monitor vital signs, GCS, blood sugar, specific signs depending on agent
IV access if & when toxicity manifests
Cardiac monitoring depending on agent
Home in daylight hours only

[KH] Risk Assessment over a Thousand Miles?

[KH] Agents where treatment different from adults:
Paracetamol
Benzodiazepines
Agents causing bradycardia

[all] Summary

Shout-outs to:
Perth Toxicologists a-plenty…
LITFL Crew @sandnsurf @antidoped
TPR – The Poison Review @poisonreview

References:

Toxicology Handbook – Lindsay Murray, Frank Daly, Mark Little, Mike Cadogan
2nd Edition (esp Chapter 1 and pg 120-125)

Australian Poisons Information Centre: Freecall 13 11 26 (Australia)

This debate is going to be HUGE… Does paracetamol (acetaminophen) cause asthma?

A series of large international studies and reviews dedicated to the question raise some interesting questions.  There appears to be an epidemiological association – not the same as a causal association – but something’s going on…

For those of us who have been using APAP (=acetaminophen, =paracetamol) liberally throughout our paediatric careers, this new evidence comes as bit of a shock.  You can hear it in the way we talk about these studies – trying not to let evidence get in the way of our own prejudices!

Outline: ISAAC vs APAP

[cp] Welcome, introduction, disclaimer

[cp] Background
Previous PEMcasts on fever and antipyretics

Advantages of antipyretics:

• relieve pain
• improve comfort
• can facilitate clinical assessment

[sf] Disadvantages of antipyretics:

• Do not prevent febrile convulsions
• May increase fever phobia
• Unhelpful in risk stratifying Fever Without Source
• May prolong infective illness
• Impair immune response to vaccination

[RR] APAP = N-Acetyl Para-Amino-Phenol
= acetaminophen = paracetamol
Most widely used drug in pediatrics, increasing use in last 30 years.
Recent market favour towards ibuprofen despite concerns of gastric inflammation, renal damage, wheezing.

[cp] Several papers now added to initial ISAAC 2008 publication; lessons from history include aspirin, phenacetin, thalidomide.

[cp] Beasley 2008 & accompanying editorial (Barr 2008)

[sf] Etminan 2009

[cp] Beasley 2011

[RR] McBride 2011

Often referenced: Lesko 2002

[all] Conclusions, goodbye

References

Beasley R, Clayton T, Crane J, von Mutius E, Lai CK, Montefort S, Stewart A;
ISAAC Phase Three Study Group.
Association between paracetamol use in infancy and childhood, and risk of asthma, rhinoconjunctivitis, and eczema in children aged 6-7 years: analysis from Phase Three of the ISAAC programme.
Lancet. 2008 Sep 20;372(9643):1039-48. PubMed PMID: 18805332.

Barr RG.
Does paracetamol cause asthma in children? Time to remove the guesswork.
Lancet. 2008 Sep 20;372(9643):1011-2. PubMed PMID: 18805311.

Etminan M, Sadatsafavi M, Jafari S, Doyle-Waters M, Aminzadeh K, Fitzgerald JM.
Acetaminophen use and the risk of asthma in children and adults: a systematic
review and metaanalysis.
Chest. 2009 Nov;136(5):1316-23. Epub 2009 Aug 20. Review. PubMed PMID: 19696122.

Beasley RW, Clayton TO, Crane J, Lai CK, Montefort SR, Mutius E, Stewart AW;
ISAAC Phase Three Study Group.
Acetaminophen use and risk of asthma, rhinoconjunctivitis, and eczema in adolescents: International Study of Asthma and Allergies in Childhood Phase Three.
Am J Respir Crit Care Med. 2011 Jan 15;183(2):171-8. Epub 2010 Aug 13. PubMed PMID: 20709817.

McBride JT.
The association of acetaminophen and asthma prevalence and severity.
Pediatrics. 2011 Dec;128(6):1181-5. Epub 2011 Nov 7. PubMed PMID: 22065272.

Lesko SM, Louik C, Vezina RM, Mitchell AA.
Asthma morbidity after the short-term use of ibuprofen in children.
Pediatrics. 2002 Feb;109(2):E20. PubMed PMID: 11826230.

ISAAC Website: http://isaac.auckland.ac.nz/

Well babies can cause angst too… Except that neither parents nor doctors can be sure that they are well, until they have been properly assessed. From funny breathing to blue lips, baby boobs to milk regurgitation, a range of neonatal and infant oddities can present to our Emergency Departments.

Some of these babies have real pathology and some have a minor but scary condition, with a great deal of ‘normal for young babies’ thrown into the mix. In this episode we discuss a few common problems, and provide some pointers towards differentiating baby wellness from baby illness. A huge thank-you to Dr Kate Bradman for allowing us to use her ‘Small Babies’ guideline!

PEMcast outline: Well Baby Oddities

Introduction, welcome, disclaimer

‘My baby is breathing very fast or seems to stop breathing’. There is no colour change.
Could be: Periodic breathing
Babies have an immature respiratory centre. When they breathe normally they blow off their CO2 – this causes them to become hypocapnoeic, and they stop breathing in response. This causes their CO2 to increase and they then become tachypnoeic to blow off their increased CO2 and they subsequently become hypocapnoeic and the cycle starts again…

‘My baby’s lips turn blue when he feeds’
Could be: Peri-oral cyanosis
There is a venous plexus below the top lip, when the baby sucks this becomes engorged and is visible through the skin. The important thing is to ensure that it is the area around the lips that turn blue and not the mucosa, and that the baby is feeding well, not sweating during feeds and is growing normally.
Concerning features:
Recession/Grunting or Stridor
Coughing especially after feeding
Tachypnoea with reduced feeding

‘My baby hasn’t opened their bowels for 5 days’
Could be: Normal neonatal bowel function
It is completely normal for babies to not open their bowels for up to 7 days at any one point. This is especially common in breast-fed babies. Initially breast-fed babies open their bowels regularly as colostrum is a stimulant laxative. This clears out the meconium and their poo changes to a yellow seeded mustard consistency.
Concerning features:
Meconium not passed in first 24-48 hours of life – these babies must be referred to a surgeon
Excessive straining to pass stool
Blood passed with stool

‘My baby vomits after every feed’
Possible Diagnoses:
1. Possetting – all babies posset (bring up a small amount of milk after feeding). It is a normal mild form of GOR – the sphincter muscle at the oesophago-gastric junction is weak and they are fed a liquid diet, and spend most of the time lying down; they also swallow a lot of air whilst feeding, and burping causes a small amount of milk to return.
2. Overfeeding – a full-term healthy baby should feed (from Day 4) about 150 mls/kg/day, divided into regular 2-4 hourly feeds. It is vital that all babies you see have a calculated total daily intake of milk written as mls/kg/day. For breast-fed babies it is useful to document how often they are feeding, and for how long, and whether they are having bottle top-ups.
3. Gastro-oesophageal reflux – as explained above all babies reflux to some degree.
The first step in treating reflux is positioning: during feeding, and for at least 30 mins after feeding, the baby should be kept as upright as possible. Regular winding during feeds can also help.
In addition, feed thickeners can be used – mixed with water and given via syringe for breast-fed babies, or added to formula milk. Corn-flour works just as well as commercial products.
Parents should be advised that most babies will grow out of this condition once solids are introduced.
There are 2 concerning types of reflux that result in poor weight gain and therefore require treatment and/or further investigation:
Painful reflux – acid is refluxed into the oesophagus and the baby screams during feeds and refuses feeds. This type of reflux often responds to proton pump inhibitors e.g. omeprazole, lansoprasole
Excessive vomiting – with failure to gain weight and / or regular episodes of aspiration pneumonia. These babies should be referred for investigation. In many cases the only effective treatment is a Nissen fundoplication.
Concerning features:
Fever & vomiting
Projectile non-bilious vomiting in a hungry baby (pyloric stenosis)
Bilious vomiting (surgical obstruction)
Vomiting in a baby who looks unwell
Weight loss or failure to regain birth weight

‘My baby has blood in his wee’
Could be: Urate crystals
Excretion of calcium and urate in the urine can be visible as orange-red staining in the nappy. It is extremely common in the first few days of life, but can be a sign of significant dehydration later on.

‘My baby is bleeding from her vagina’
Diagnosis: Hormonal withdrawal
This is a completely benign and common condition that freaks parents out – especially fathers! It is related to maternal hormone (progesterone) withdrawal, and only lasts a few days.
Concerning features:
PV bleeding outside the neonatal period

‘My baby boy has boobs’
Diagnosis: Response to maternal hormones
This can occur in both male and female neonates and is completely benign and self-resolving.
Concerning features:
Breast enlargement with onset outside the neonatal period
Unilateral swelling
Hot red swelling
Pus formation

‘My baby is producing breast milk’
Diagnosis: Maternal hormone response – ‘Witches milk’
As above, this is a completely benign, if somewhat alarming, condition which occurs in neonates as a result of maternal hormones crossing the placenta before birth.

‘My baby is moving funny – are they fitting?’
Could be: Moro Reflex – ‘Startle response’
Normal response to noise, sudden movement or touch. The reflex is present from birth and disappears by about 4-6 months of age.
Concerning features:
Tonic-clonic movements
Unilateral movements
Associated colour change

‘My baby isn’t gaining weight’
Understanding weight loss and gain in the neonatal period is vital. Your assessment of any infant should include plotting their weight and head circumference on an appropriate growth chart.
Day 1: Birth weight
First week of life: Weight loss – up to 10% of the birth weight is acceptable
Day 10-14: Baby should have regained their birth weight
Further weight gain can be remembered by the old adage ‘an ounce (30g) a day except on Sundays’ i.e. a healthy baby should gain around 180g per week
Average weights (50th centile):
Birth: 3.5 kg
6 weeks: 4.0kg
Six months: 7 kg
1 year: 10 kg

‘My baby has spots’
Could be: Erythema Toxicum (Neonatorum)
Most common pustular eruption in newborns
Aetiology is unknown (sterile collections of eosinophils)
Usually appear day 2-3 and fade by day 7 although they may recur for several weeks
Fluctuating generalised eruption
No treatment is needed

Could be: Milia (‘Milk Spots’)
Caused by retention of keratin within the dermis
Occur mainly on face but can occur anywhere
Usually disappear within the first month
No treatment is needed

Suggested websites for parents (Australian):
Health Direct – http://www.healthdirect.org.au/pbb
Raising Children – http://raisingchildren.net.au/

Young infants under 3 months can be pretty scary when they get properly sick. It seems quite ‘veterinary’, and in many ways we just have to screen and treat for sepsis – and ask questions later… But there are a number of other differentials to consider.

Signs of illness may be obvious, such as when we are presented with a pale, floppy baby, or they may be more subtle – when either the caregiver or the doctor just knows that the baby is just NQR – Not Quite Right. In this episode, we consider the assessment and management of the non-specifically unwell young infant, that is, under 3 months of age, using an ABCD structure (of course).

PEMcast Outline: undifferentiated sick young infant (<3 months)

[CP] Intro, disclaimer

[RR] What’s different about neonates / young infants?
They are brand new
Physiological changes
Possibly inexperienced parents
No chance to know what is “normal” for them
They are SCARY!
However…It is easy once you have a system as we have such a low threshold for investigation and treatment.

[CP] The background history
Antenatal problems
Birth- PROM, distress, NICU
Family history
Vitamin K

[RR] History & Examination: Systematic approach

[CP] Airway & Breathing Problems

Hx:
Congenital problems?
Progressive problem, or manifests with episodes of Infection?
Ex:  Stridor, Air entry, Sats,
Ix: CXR

[RR] Circulation

Hx:
Antenatal scans don’t pick up everything
Many cardiac problems progress over first few days (duct closure)
Feeding – tiring / sweating
Weight gain less obvious (peripheral oedema does not really happen)
Ex:
Sometimes it is easy to spot cyanosis…. (smurf)
Usually it isn’t- do saturations on both arms (pre and post ductal)
Listen for murmurs and feel for a liver
Always feel for femoral pulses
Ix: ECG and CXR

[CP] Disability (and sepsis)
Hx:
Antenatal risk factors
Fever?- if any documented fever TREAT as sepsis
Ex:
Posture?
How does the baby handle? (reactive? lively on handling?)
Fontanelle
Blood sugar (DEFG)
Ix:
? Sepsis: If any concern about sepsis- full septic screen (incl urine, CXR, BC, CSF)
? Cardiac- CXR and ECG
? Metabolic- urine, full septic screen, ammonia and cortisol

[RR] Treatment
Sepsis- cefotaxime, gentamicin and amoxycillin
Cardiac- prostin to keep duct open
Metabolic- IV glucose and NBM

Differentials for the collapsed young infant:

[CP] A: (congenital airway abnormality) Allergy/anaphylaxis

[RR] B: apnea (RSV/FB), ALTE, pneumonia, pneumothorax

[CP] C: coarctation, duct-dependent pulmonary or systemic circulation, SVT

[RR] D: intracranial bleed eg Vitamin K deficiency, NB inflicted injury (NAI)
Envenomation or poisoning (DIMTOPPE mnemonic)

[CP] E: (fever – sepsis): UTI, bacteraemia, meningitis, viraemia

[RR] DEFG: Hypoglycaemia, other metabolic incl CAH (boys)

[CP] GI: Intussusception, other causes of bowel obstruction (green vomits) incl obstructed inguinal hernia

[CP] ALTE’s: a well baby that gets admitted (see previous PEMcast)
4 features (Detailed history is important)
Not a ‘near-miss SIDS’
[RR] Should be taken seriously and needs paediatric follow-up
Encourage parents to go on a life support course
Many parents buy apnoea alarms (pros & cons)

[RR] Summary
Most unwell babies will be treated for sepsis pending further investigation
It is important to look for cardiac and metabolic problems
Don’t forget Non-Accidental Injury as a differential

Here’s a bit of fun… And some lessons for Pediatric Emergency Medicine, from 1971.
It’s a kid’s book, about a boy who hurts his finger at school, and has to see the school nurse.  James feels Just Awful – until after the 3-part treatment.

We learn about assessing, cleaning and dressing wounds, and gain some insights into a child’s perspective of being a patient.

Enjoy.

Just Awful on YouTube

Download Video

A tiny, frightening little bug: Neisseria meningitidis.  The challenge for us in healthcare is to squash this little bug before it wreaks its havoc…

Join us for a discussion of ways to protect yourself, and your patients, against the nasty threat of meningococcal disease. It creeps up on you… when you least expect.

Outline: MCD PEMcast

[cp]: Intro, welcome, disclaimer

[cp]: Problematic disease because of non-specific early clinical picture, rapid progression, potentially devastating outcomes, and because relatively uncommon (therefore difficult to get useful data/research)

[CB]: Vaccination covers some serotypes (which?)

[cp]: Challenge / Holy Grail is early diagnosis (& treatment); strategies to try to achieve this are:
- public awareness (more good than harm, despite occasional parent not being reassurable) (organisations, tumbler test)
- healthcare professionals awareness
- formal guidelines & protocols eg early parenteral antibiotics via GP or peripheral setting, prior to transfer to hospital, standardised risk-management protocols eg antibiotic guidelines, ICU consultation, etc
- search for a new test / combination of tests / scoring system etc

[cp]: Clinical features (which stand out from other causes of sepsis or meningitis):
- individually lack specificity but might raise your suspicions
[RR]: – symptoms: non-blanching rash, leg pain, rapid deterioration, others
[cp]: – signs: petechiae / purpura, cold peripheries (toe-core temperature gradient used in Glasgow meningococcal sepsis score), others

[all / cp]: Protective strategies for ED docs:
- be afraid, this disease is deceptive
- a piece of hay that turns into a needle…
- documentation – descriptive, including lay terminology, to paint an accurate clinical picture
- discharge advice for parents in setting of ‘viral illness’ or fever without source
- utilise period of observation when unsure
- keep looking out for new strategies to minimize your own risk

[CB]: Comments from Chris

[all] summary, goodbye

The most important thing about treating meningitis is to give antibiotics as soon as possible.  The second most important thing is to institute appropriate supportive care.  Whether or not to give steroids as an adjunctive treatment is perhaps less clear to us…

A recent Cochrane review goes a long way to pointing us in the right direction, but still leaves a few questions open.  Join us for a quick tour of the literature and guidelines, in our quest for the truth about using steroids in meningitis.

Outline: Steroids for Meningitis PEMcast

[cp]: intro, disclaimer, rationale / theory: decrease inflammatory damage due to bacterial lysis

[cp]: Historical background: original studies were from an era when Haemophilus & Strep were common, decreased by vaccinations
?applicability to current (developed world) population of children and infectious agents

[CB]: Comments from Chris

Papers:

[RR]: Kennedy 1991 AmJDisChild – Pneumococcus

[cp]: Gupta 2004 ArchDisChild – Meningococcus

[cp]: Brouwer 2010 Cochrane review

[CB]: Peltola 2010 Pediatrics

Guidelines:

[cp] AAP (nothing recent – litigation fear??)
1990 guideline regarding steroids in meningitis
Nigrovic 2007 JAMA (Bacterial Meningitis Score)

[RR]: NICE Guideline (esp section 1.4.39 – steroids): Over 3 months age, start ASAP if within 12 hours: dexamethasone 0.15mg/kg IV, 6-hourly for 4 days
http://guidance.nice.org.uk/CG102

Review of NICE Guidance by Radcliffe, October 2011

[RR]: SIGN Guideline (esp section 6.4.2) Invasive MCD, start within 24 hours
http://www.sign.ac.uk/guidelines/fulltext/102/index.html

[cp/CB]: local guidelines (dexamethasone 0.2mg/kg IV 6-hourly)

[all] Summary, goodbye

References

Kennedy WA, Hoyt MJ, McCracken GH Jr.
The role of corticosteroid therapy in children with pneumococcal meningitis.
Am J Dis Child. 1991 Dec;145(12):1374-8.
PubMed PMID: 1669663.

Gupta S, Tuladhar AB.
Does early administration of dexamethasone improve neurological outcome in children with meningococcal meningitis?
Arch Dis Child. 2004 Jan;89(1):82-3. Review. PubMed PMID: 14709520.

Brouwer MC, McIntyre P, de Gans J, Prasad K, van de Beek D.
Corticosteroids for acute bacterial meningitis.
Cochrane Database Syst Rev. 2010 Sep 8;(9):CD004405. Review. PubMed PMID: 20824838.

Peltola H, Roine I, Fernández J, González Mata A, Zavala I, Gonzalez Ayala S,
Arbo A, Bologna R, Goyo J, López E, Miño G, Dourado de Andrade S, Sarna S,
Jauhiainen T.
Hearing impairment in childhood bacterial meningitis is little relieved by dexamethasone or glycerol.
Pediatrics. 2010 Jan;125(1):e1-8. Epub 2009 Dec 14. PubMed PMID: 20008417.

American Academy of Pediatrics Committee on Infectious Diseases:
Dexamethasone therapy for bacterial meningitis in infants and children.
Pediatrics. 1990 Jul;86(1):130-3. PubMed PMID: 2193301.

Nigrovic LE, Kuppermann N, Macias CG, Cannavino CR, Moro-Sutherland DM,
Schremmer RD, Schwab SH, Agrawal D, Mansour KM, Bennett JE, Katsogridakis YL,
Mohseni MM, Bulloch B, Steele DW, Kaplan RL, Herman MI, Bandyopadhyay S, Dayan P, Truong UT, Wang VJ, Bonsu BK, Chapman JL, Kanegaye JT, Malley R; Pediatric Emergency Medicine Collaborative Research Committee of the American Academy of Pediatrics.
Clinical prediction rule for identifying children with cerebrospinal fluid pleocytosis at very low risk of bacterial meningitis.
JAMA. 2007 Jan 3;297(1):52-60. PubMed PMID: 17200475.

National Institute for Health and Clinical Excellence
The management of bacterial meningitis and meningococcal septicaemia in children and young people younger than 16 years in primary and secondary care
Last updated: 10 November 2011
http://guidance.nice.org.uk/CG102

Radcliffe RH.
Review of the NICE guidance on bacterial meningitis and meningococcal septicaemia.
Arch Dis Child Educ Pract Ed. 2011 Oct 27. [Epub ahead of print] PubMed PMID: 22034519.

Scottish Intercollegiate Guidelines Network
Management of Invasive Meningococcal Disease in Children and Young People
Guideline No. 102, ISBN 978 1 905813 31 5, May 2008
http://www.sign.ac.uk/guidelines/fulltext/102/index.html

The word strikes fear into the heart of parents. You dare not mention the ‘M’ word unless you back it up with action, or a whole heap of calming reassurance…

The clinical features of meningitis are less straightforward in younger children, and CSF findings can be tricky to interpret. In this episode, our local Paediatric Infectious Diseases expert guides us through the topic with some clinical perspectives and insights.

Meningitis PEMcast: Outline

[cp]: intro / disclaimer

[cp]: clarification – meningitis (definition) vs meningococcal disease [MCD] (spectrum of meningitis, meningococcaemia, or both)

[all]: MCD prognosis depending on this spectrum, why?

[cp]: clarification meningitis vs encephalitis / meningo-encephalitis

Aetiology:

[cp]: – Non-infectious (‘aseptic’=non-bacterial): autoimmune, neoplastic, drug-induced

- Infectious

[RR]: viral – frequent offenders (Entero= Coxsackie/Echo, HSV less common)

[sf]: bacterial – frequent offenders

neonatal: maternal (Listeria,  Group B Strep) vs acquired source (E coli, Gram-negatives, eg Klebsiella, Staph aureus)

beyond neonatal period: Strep pneumoniae, Neisseria meningitidis, Haemophilus influenzae type B

[CB]: less common pathogens – mycobacterium tuberculosis, measles, mumps, fungal, cryptococcal in immunocompromised kids

Clinical features:

[RR]: History (headache, neck stiffness, photophobia, fever – or hypothermia in neonates)

[sf]: Examination findings (fever, meningeal irritation, rarely Brudzinski or Kernig signs, altered mental state, focal neurology, seizures, drowsiness, irritability)

[cp]: differential diagnoses (including alternate causes of fever, altered mental state, headache, neck stiffness) esp Viral illness / influenza, tonsillitis, infant sepsis (eg UTI), non-specific infant unwellness (metabolic, cardiac, intussusception)

Absence of meningism is not reassuring in the younger child!

Investigations:

[RR]: bedside – blood sugar, urinalysis (differentials), ECG maybe

[sf]: lab – utility of FBC, U&E, CRP, ESR?
[cp]: lab – role for procalcitonin?

[CB]: lab – blood cultures – how often do we get the bacterium on blood culture?

[CB]: Timing of LP (do the LP as soon as it’s safe to do it)

[RR]: imaging – need for CT prior to LP? (compare adults vs children)

[sf]: Lumbar Puncture: cautions / contraindications (raised ICP, focal seizure, seizure without full recovery, cardiovascular or respiratory compromise)
Lower threshold for LP if recent oral antibiotics, esp if febrile convulsion

Needle depth (CHW): 1.5 mm/kg (for under 10kg), 1mm/kg (10-40kg)

CSF findings:

[cp]: – normal (age-related)

[sf]: – typical viral picture (not useful in acute stage – treat as bacterial)

[RR]: – typical bacterial picture

[CB]: – oddballs: fungal, TB, Mumps

Management:

[cp]: Steroids? Best given “before” antibiotics – role to be discussed in next episode

[RR]: Presumed or confirmed bacterial: IV antibiotics
- antibiotic choice – local guidelines, neonates different (amoxycillin for Listeria, gentamicin, cefotaxime – avoid ceftriaxone – biliary sludging)
- antibiotic duration (?stop at 48 hrs when all cultures negative, vs several weeks for some organisms)
- waters muddied by prior oral antibiotic treatment

[sf]: Presumed or likely Viral:
- usually will get antibiotics initially
- supportive care (caution with IV fluids)
- when to give antiviral agent? (HSV, VZV?)
- acyclovir dosing – body surface area vs simple weight-based 10mg/kg

[CB]: Exotic bugs (immunocompromised / travel / cranial or spinal neurosurgery) – get Microbiology / Infectious Diseases specialist advice!

[all]: last words, goodbye

Everyone’s doing it… Is it time for your Pediatric ED to join the UltraSound craze?  For adult Emergency Medicine, there seems to be a strong following and a reasonable evidence-base.  That may be coming to the kiddy world, but maybe it’s not all that it’s cracked up to be?

In this episode, we discuss the evolution of bedside clinical ultrasound use in the pediatric emergency medicine setting.  As always, we’d love to hear your comments…

Outline: Ultrasound PEMcast

CP: Intro, disclaimer, EBM-light discussion…
Levy & Noble 2008 (Pediatrics) gives a reasonable overview (full reference below).

CP: overview:
Established uses in Adult EM
Translation to PEM setting
Procedural uses in PEM
Diagnostic uses in PEM
New & crazy directions

JCR: What got you interested in UltraSound?

CP: Established uses in Adult EM
Diagnostic: FAST
Aorta
Procedural: CVC
Femoral Nerve Block
JCR: extending diagnostic uses: DVT, resuscitation/shock, Echo, [for experts: gallstones, pneumothorax, retinal detachment, more]
and Procedural uses: vascular access, nerve blocks, fracture reduction [more]

RR: Advantages of translating U/S skills to PEM setting?
no radiation
aid to clinical skills
improved success with procedures
potential to save time
potential to increase parent/patient satisfaction
look cool…

CP: Barriers to implementing U/S in the Paediatric ED:
lack of skilled users
trauma infrequent (& often conservatively managed)
operator-dependent (therefore medicolegal risk with diagnostic studies)
resistance to change (within ED and even Radiology Dept)
less cooperative patients

RR: Procedural uses in PEM
Vascular access esp CVC
Nerve blocks esp Femoral Nerve Block
For the brave:
foreign body localisation & removal
fracture reduction
joint aspiration
abscess incision & drainage
lumbar puncture

JCR [comment]

CP: Diagnostic uses in PEM
Bladder volume (pre-SPA)
Volume status – IVC: Aorta ratio
Hip effusion
For the brave:
appendicitis
pyloric stenosis
pregnancy
intussusception
echo (innocent murmur)

JCR [comment]

JCR: Evidence base supporting the use of UltraSound by Emergency Physicians?

RR: New & crazy directions
ETT placement (confirmation)(either directly scanning trachea, or visualising sliding pleura)
ETT sizing pre-intubation (using a formula)
Raised intracranial pressure (optic nerve diameter)
Fractures of skull, tibia (toddlers fractures missed on X-Ray)
Peritonsillar abscess
Scrotal pain (suspected torsion)
?minor head injury in infants with open fontanelle (risky)

CP: personal track-record theory

JCR: Credentialling in Australia (& worldwide)
Further qualifications in U/S

All: Summary, goodbye

By the way… check out www.UltraSoundVillage.com

Reference

Levy JA, Noble VE.
Bedside ultrasound in pediatric emergency medicine.
Pediatrics. 2008 May;121(5):e1404-12. Review. PubMed PMID: 18450883.

Last time we spoke about intussusception and its treatment.  This week, we try to discover whether there is a real link between rotavirus vaccines and this rare cause of abdominal pain in infants.

Discussing vaccine efficacy and risks often engenders strong feelings from both sides of the river… the traditional believers AND the ‘anti-vaxxers’.  As with many controversies, it depends how you interpret the numbers – where your innate beliefs lie will influence how you see the data.  Join us as we try to walk the middle ground of objectivity…

Intussusception: Is Rotavirus Vaccination a real risk?

[cp] intro, disclaimer, overview

[cp] History: the RotaShield experience

Evidence – selected papers:
[rr] Belongia 2010 (USA surveillance)
[sf] TGA-Study 2011 (Australia)
[cp] Buttery 2011 (post-marketing surveillance Australia)
[sf] Patel 2011 NEJM (Mexico & Brazil)
[rr] Greenberg 2011 NEJM (editorial of Patel paper)
[cp] (similar studies/reports from numerous countries)

WHO position:
[cp] 2007 position paper
[rr] 2009 update of position paper (& NUVI implementation statement)
[sf] 2011 safety statement

Australian Health authorities’ position:
[cp] CMO letter 2011
[sf] Health Department Provider Info

Current practicalities:
[cp] Immunisation Handbook (Ch 3.18 Rotavirus)
[rr] Choice of vaccine
[sf] Timing of vaccination (catch-ups ?not allowed)
[cp] Both rotavirus infection and intussusception are Notifiable Diseases in (Western) Australia

[all] Summary, goodbye

ZDogg MD says: Immunize!

ZDoggMD \”Immunize!\” on YouTube

References

Belongia EA, Irving SA, Shui IM, Kulldorff M, Lewis E, Yin R, Lieu TA, Weintraub E, Yih WK, Li R, Baggs J; Vaccine Safety Datalink Investigation Group.
Real-time surveillance to assess risk of intussusception and other adverse events after pentavalent, bovine-derived rotavirus vaccine.
Pediatr Infect Dis J. 2010 Jan;29(1):1-5. PubMed PMID: 19907356.

Rotavirus vaccination and risk of intussusception
Therapeutic Goods Administration
25 February 2011
http://www.tga.gov.au/safety/alerts-medicine-rotavirus-110225.htm

Buttery JP, Danchin MH, Lee KJ, Carlin JB, McIntyre PB, Elliott EJ, Booy R, Bines JE; PAEDS/APSU Study Group.
Intussusception following rotavirus vaccine administration: post-marketing surveillance in the National Immunization Program in Australia.
Vaccine. 2011 Apr 5;29(16):3061-6. PubMed PMID: 21316503.

Patel MM, López-Collada VR, Bulhões MM, De Oliveira LH, Bautista Márquez A, Flannery B, Esparza-Aguilar M, Montenegro Renoiner EI, Luna-Cruz ME, Sato HK, Hernández-Hernández Ldel C, Toledo-Cortina G, Cerón-Rodríguez M, Osnaya-Romero N, Martínez-Alcazar M, Aguinaga-Villasenor RG, Plascencia-Hernández A, Fojaco-González F, Hernández-Peredo Rezk G, Gutierrez-Ramírez SF, Dorame-Castillo R, Tinajero-Pizano R, Mercado-Villegas B, Barbosa MR, Maluf EM, Ferreira LB, de Carvalho FM, dos Santos AR, Cesar ED, de Oliveira ME, Silva CL, de Los Angeles Cortes M, Ruiz Matus C, Tate J, Gargiullo P, Parashar UD.
Intussusception risk and health benefits of rotavirus vaccination in Mexico and Brazil.
N Engl J Med. 2011 Jun 16;364(24):2283-92. PubMed PMID: 21675888.

Greenberg HB.
Rotavirus vaccination and intussusception–act two.
N Engl J Med. 2011 Jun 16;364(24):2354-5. PubMed PMID: 21675894.

Rotavirus Vaccines
World Health Organization
Weekly Epidemiological Record (WER) 10 August 2007, vol. 82, 32 (pp 285–296)
http://www.who.int/wer/2007/wer8232/en/index.html

Rotavirus Vaccines: an update
World Health Organization
Weekly Epidemiological Record (WER) 18 December 2009, vol. 84, 50 (pp 533–540)
http://www.who.int/wer/2009/wer8451_52/en/index.html

New and Under-utilized Vaccines Implementation (NUVI): Rotavirus
World Health Organization
Updated November 2009
http://www.who.int/nuvi/rotavirus/en/

Rotavirus vaccine and intussusception
Global Advisory Committee on Vaccine Safety
World Health Organization 2011
http://www.who.int/vaccine_safety/topics/rotavirus/rotarix_and_rotateq/Dec_2010/en/index.html
Extract from report of GACVS meeting of 8-9 December 2010, published in the WHO Weekly Epidemiological Report on 28 January 2011:http://www.who.int/wer/2011/wer8605/en/index.html

CMO Letter on Intussusception and rotavirus vaccine
Immunise Australia Program
Department of Health and Ageing (Australian Government)
http://www.immunise.health.gov.au/internet/immunise/publishing.nsf/Content/immunise-cmo-intussusception

Rotavirus vaccine and intussusception: Information for Immunisation Providers
Immunise Australia Program
Department of Health and Ageing (Australian Government)
http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/ITO135-cnt

The Australian Immunisation Handbook 9th Edition 2008
http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-home
Rotavirus Chapter:
http://immunise.health.gov.au/internet/immunise/publishing.nsf/Content/Handbook-rotavirus

Australian national notifiable diseases and case definitions
Department of Health and Ageing (Australian Government)
http://www.health.gov.au/internet/main/publishing.nsf/Content/cdna-casedefinitions.htm

Intussusception is a ‘telescoping’ of the bowel on itself, commonest in infants between 5 and 10 months of age.  Usually, the classic triad of abdominal pain, vomiting and red-currant-jelly stools is not present, so how do we diagnose this sneaky little condition?

In this episode, we explore the clinical presentation, investigation and management of this bowel-threatening condition.

Outline: Intussusception PEMcast

[cp] intro, disclaimer, background

[cp] History (of the condition)
[rr] Aetiology & Pathophysiology
[sf] Incidence (worldwide)
[cp] incidence in Australia, and at our hospital

[sf] Clinical: History
[rr] Examination findings (caution about triad – usually not the case; highlight pallor – including parental report of)
[cp] Differential diagnoses (including causes of altered conscious state)
[rr] Investigations: AXR
[sf] Investigations: U/S

[cp] Treatment: air enema
[rr] Treatment: surgical reduction

[sf] Complications (including perforation, recurrence)

[all] Summary, goodbye

References & Further Reading

Blanco FC
Intussusception
Medscape Reference
http://emedicine.medscape.com/article/930708-overview

Irish MS
Pediatric Intussusception Surgery
Medscape Reference
http://emedicine.medscape.com/article/937730-overview

Winslow BT, Westfall JM, Nicholas RA.
Intussusception.
Am Fam Physician. 1996 Jul;54(1):213-7, 220. Review. PubMed PMID: 8677837.

Applegate KE.
Clinically suspected intussusception in children: evidence-based review and self-assessment module.
AJR Am J Roentgenol. 2005 Sep;185(3 Suppl):S175-83. Review.
Erratum in: AJR Am J Roentgenol. 2005 Dec;185(6 Suppl):S213. PubMed PMID: 16120899.

Assessing the risk of self harm or suicide in adolescents is a daunting concept for the occassional player.  Many Emergency Departments have a qualified Mental Health professional embedded in their clinical workforce… which means that we can become de-skilled in the art of risk assessment.

Last time, we discussed the HEADSS assessment tool for communicating with adolescent patients, and this is a great place to start.  In this episode we explore some of the elements of a structured mental health assessment.

Outline:  Self-Harm Risk Assessment

Usual to have low mood at times (due to challenges, etc)
Assessment = History, Examination, “Special investigations”
ie History, Mental State Examination, +/- structured assessment tool, +/- referral to Mental Health professional

Why do people harm themselves?
The effect of cultural / social trends

Structured suicide risk-assessment scores eg Pierce, SADPERSONS, etc
-evidence of validity?
-widely used? or not?
-applicable to adolescents?

PATHOS assessment tool (chronicity, planning, hopelessness)

HEADSS assessment as a structured conversation

Management options:
Medical management in parallel with psychiatric and other issues (eg self-poisoning, self-harm injuries)
Reassurance alone may occassionally be sufficient
Referral to Mental Health professional – acutely or follow-up
Short-term agreement / contract to not self-harm
Social work – support services, organisations, financial, legal, etc
Drug & alcohol / addiction medicine service
Sexual health services
Medications ? (caution with benzos; SSRIs – may suggest to GP but dont start in ED)

It’s a tough transition, from childhood to adulthood… some of us are still trying to grow up. Looking after teenagers in a medical context can be tricky too – how can you be cool, without looking like a fool?

In this episode we discuss the challenges of establishing trust, and making a thorough and balanced assessment in a busy, noisy Emergency Department. The HEADSS assessment tool is a great way to start the ball rolling… Check out Colin’s pseudo-British accent in the role-play!

[cp] Introduction, disclaimer

[kb] Definition of adolescence
Cutoff age =16 at our hospital, 18 in US, Adolescent medicine considered by some to be up to 25 yrs age

[rr] Challenges of being a teenager
ie changing body, societal role, expectations, impending career, friends / bullying (including cyber-bullying), belief system, family

[cp] Challenges of caring for teenagers
ie autonomy, risk-taking behaviour, privacy issues vs parents, communication, attitude, limited experience & intellectual capacity

[kb] [rr] Presentations to ED:
Usual medical/surgical conditions +/- modified presentation (eg torsion & shyness, compliance with chronic conditions eg diabetes, asthma)
Mental health / behavioural / self-harm
Sexual health issues
The case for Adolescent Medicine as a subspecialty
eg transition to Adult services for chronic conditions

[rr] UK‘s RCPCH Adolescent Health Programme

[all] HEADSS:
H: Home environment
E: Education & Employment
(E: Eating)
A: peer-related Activities
D: Drugs
S: Sexuality
S: Suicide/depression
(S: Safety from injury & violence)

Opening lines, good and bad (refer to Table 2 in Goldenring & Rosen 2004 paper):
-exploring ways of communicating with young people.

[all] Goodbye, catch you next time!

References

Getting into Adolescent Heads: an essential update
John Goldenring & David Rosen
Contemporary Pediatrics, Jan 1,  2004
http://www.aap.org/pubserv/psvpreview/pages/Files/HEADSS.pdf

Goldenring JM, Cohen E: Getting into adolescent heads.
Contemporary Pediatrics 1988;5(7):75

A recent paper about fluid boluses in sick African children has raised a few eyebrows around the world of pediatric emergency medicine, and the world of medicine in general…

We thought we’d get in on the discussion, before everyone goes throwing the baby out with the bathwater.  In this PEMcast we try to appraise the Maitland paper in a rational, unemotional way… and almost manage!

Fluid Controversies PEMcast

[cp] Introduction, disclaimer

[kb] IntraVenous fluid can be for:

• resuscitation – replacing intravascular volume
• maintenance – replacing insensible losses and metabolic requirements
• rehydration – rehydrating dessicated tissues (interstitial and intracellular fluid)
• ongoing losses (large loose stools or large vomits)

[rr] Controversies regarding type, rates and volumes of fluids, for resuscitation and maintenance/rehydration.
Crystalloid vs Colloid (essentially dead debate, but Albumin still a bit controversial)
Isotonic vs Hypotonic fluids (see Circulation PEMcast for detailed discussion)
Rapid vs slower rehydration
Low-volume resuscitation in trauma

[kb] Accepted conventional wisdom:
Shock: 10-20mL boluses of Normal Saline
Haemorrhagic Shock: 10mL/kg of blood
Maintenance & Rehydration fluid: Normal Saline + 5% dextrose (esp in younger kids under 5 years)
Slower / more cautious fluids in DKA, meningitis, pneumonia, bronchiolitis, post-operatively, or any other situation where increased ADH secretion is likely (head and chest pathology commonly).

[cp] New data challenging our world view: options are to accept & incorporate, reject outright, accept parts we like, or ‘shelve it’ until more data becomes available…

[cp] NEJM Editorial: Fluid Resuscitation in Acute Illness – Time to Reappraise the Basics

NEJM Original Article May 2011: Mortality after Fluid Bolus in African Children with Severe Infection – Maitland et al for the FEAST Trial Group

[kb] Background: IV fluid boluses reserved for advanced shock; not widely practiced in parts of Africa
[rr] Methods: Robust design; fluid protocol increased to 40 or 60mL/kg; case definition
[cp] Statistical analysis: sample size increased due to lower mortality; subgroups under-powered?
[kb] Results: prostration 62% coma 15% resp distress 83% malaria 57% mean Hb 71; 48hr mortality 10.6 vs 10.5 vs 7.3% in stratum A
[rr] Discussion: extrapolation to other settings? Clinical differentiation of cases
[cp] Discussion (continued): Kaplan-Meier curves; few adverse events identified (?under-reported)

ADC Article June 2011: Treating the wrong children with fluids will cause harm: response to ‘mortality after fluid bolus in African children with severe infection’ – Southall & Samuels

[all] discussion: patient population, signs of shock vs illness, underlying causes, oxygen, clinical signs

[all] Conclusions and closing remarks

References

Myburgh JA.
Fluid resuscitation in acute illness–time to reappraise the basics.
N Engl J Med. 2011 Jun 30;364(26):2543-4. Epub 2011 May 26. PubMed PMID: 21615300.

Maitland K, Kiguli S, Opoka RO, Engoru C, Olupot-Olupot P, Akech SO, Nyeko R, Mtove G, Reyburn H, Lang T, Brent B, Evans JA, Tibenderana JK, Crawley J, Russell EC, Levin M, Babiker AG, Gibb DM; FEAST Trial Group.
Mortality after fluid bolus in African children with severe infection.
N Engl J Med. 2011 Jun 30;364(26):2483-95. Epub 2011 May 26. PubMed PMID: 21615299.

Southall DP, Samuels MP.
Treating the wrong children with fluids will cause harm: response to ‘mortality after fluid bolus in African children with severe infection’.
Arch Dis Child. 2011 Jun 28. [Epub ahead of print] PubMed PMID: 21715393.

So, a well-looking child turns up to triage and gets given a high triage priority, simply because they have a Congenital Metabolic Disorder.  Do we really have to jump to it, put in an IV cannula, and call the specialist?

There are individual subtleties in managing these children with Inborn Errors of Metabolism, but a few common principles apply.  This short tour of a few commoner conditions should give you a handle on this important group of patients.

Outline: Caring for the Known-IEM patient

[cp] Welcome, intro, disclaimer

Patients usually well-known to the Hospital / team
Often phone ICU / own specialist beforehand
Guidelines exist for many conditions, and specific guidelines tailored to individual patients
Basics of ED care for:

[kb] Hyperammonaemia

[cp] Organic Acidaemias (MMA & PA)

[AM] how does Carnitine help?

[RR] Glutaric Aciduria (Type 1)

[cp] Fatty Acid Oxidation disorders

Common themes: take it seriously, act fast, get help, provide substrate

[AM] rationale for Newborn screening. Is it cost effective?

[all] Thanks, goodbye

Inborn Errors of Metabolism… OK, calm down, check your own pulse, and resist the urge to run away. Nobody likes biochemistry (OK, maybe one or two do like it), but fortunately we don’t need to learn the actual biochemical pathways in order to diagnose or manage these Congenital Metabolic Disorders.

Individually these conditions are rare, but as a group they are collectively common enough that we will encounter them in our Emergency Departments.  Classifying these conditions is an ever-changing minefield, but understanding the basic principles is not too bad… especially with a bit of expert guidance from our guest brain.

Outline: Metabolic Stuff for Dummies

[cp] Welcome, Intro, disclaimer. Neonatal hypoglycaemia covered in a previous PEMcast
Reference: Claudius 2005 EM Clinics

[AM] How common are Inborn Errors of Metabolism? ie how many kids under your care, in our little city of 1.7 million (state of 2.3 million)?

[cp] All usually caused by deficiency of a protein (usually enzyme) resulting in a metabolic roadblock.
3 groups of conditions based on mechanism of illness:
-acute accumulation of toxic small molecules
-energy deficiency
-chronic accumulation of large molecules

[kb] 1. Toxic intermediates esp amino acids / organic acids accumulate after birth (removed by placenta before birth) – present on day 2-5: acidosis, altered mental state, vomiting
OR may present later in times of physiologic stress, eg viral gastro in a toddler (IEM can go undiagnosed despite several episodes)
OR toxic molecules accumulate rapidly but cause damage slowly, therefore present after neonatal period eg PKU

[RR] 2. Disorders of energy metabolism eg ‘mitochondrial disorders’ – can present prenatally with IUGR/birth defects, because ATP cannot cross membranes. Usually Autosomal Recessive, poor prognosis, characterised by severe lactic acidosis, multisystem failure; commonly have seizures, cardiomyopathy, liver disease.

[cp] 3. Chronic accumulation of large molecules eg ‘lysosomal storage disorders’ – process of storage (mostly in connective tissues) begins prenatally because large molecules cannot cross membranes – so may be apparent at birth or soon after: coarse facial features, joint contractures, heart valve disease, cataracts, loss of or failure to achieve milestones. Rarely present to ED.

[kb] When to suspect an undiagnosed metabolic disorder:
Neurologic signs, hypotonia, esp decreased conscious state more severe than expected from degree of shock/hypoglycaemia
Abnormal odours – uncommon
FHx: unexplained death / SIDS in siblings, Consanguinity (usually Autosomal Recessive conditions) – but most children with IEM have a non-contributory family history

[RR] Differential diagnoses:
sepsis (decreased temp, tachycardia, tachypnea)
- can co-exist or precipitate IEM crisis (esp for galactosaemia)
pneumonia / other respiratory condition, hypoxia
hypoglycaemia
NAI / shaken baby
congenital cardiac disease
electrolyte disturbances, CAH
malrotation
seizure disorders

[kb] What tests to request (during the episode of physiologic stress) – contents of our local ready-made bag (tube colours)
Claudius et al suggest: U&E, Cr, glucose, VBG, FBC, ammonia & lactate (both need special handling), urine dipstick for ketones & specific gravity
(consider: LFTs, INR, CK for myopathy)
Urine & blood cultures as sepsis is major differential

[RR] High Anion Gap (causes=shock, DKA, renal failure, poisoning, metabolic disease)

[AM] Where to draw the line for screening tests? How useful are specific clinical clues? (ie, just do a whole battery of tests, vs an intelligent/deductive approach)

[cp/AM] caveats:
>> hyperammonaemia can occur with other causes of acidosis due to down-regulation of the urea cycle
>> “inappropriate” large ketosis with fasting <12 hrs suggestive of organic acidaemia, but there are exceptions (complicated)
>> hypoglycaemia without ketones suggests Fatty Acid Oxidation disorder, BUT
>> normoglycaemia is more common in IEM (so don’t discount possibility of IEM if glucose normal)

[kb/AM] ED management of suspected IEM crisis (new diagnosis):
nil by mouth: stop the damaging substrate
IV dextrose
gentle hydration?
call an expert

[cp] (individual conditions to be discussed in brief next time)

[all] Goodbye, thanks for listening

References

Claudius I, Fluharty C, Boles R.
The emergency department approach to newborn and childhood metabolic crisis.
Emerg Med Clin North Am. 2005 Aug;23(3):843-83, x. Review. PubMed PMID: 15982549.

Phototherapy treatment will be sufficient for the vast majority of infants with unconjugated hyperbilirubinaemia who need treatment.  When it gets more serious, we turn to higher-risk treatments like IntraVenous Immunoglobulin or exchange transfusion. What evidence do we have to guide our decisions here?

Every Special Care Nursery in the world has a bilirubin chart on the wall to guide us in terms of phototherapy limits and when to consider exchange transfusion.  Many of these are based on a study backed by the American Academy of Pediatrics from 2004.  More recently, the National Institute for Clinical Excellence in the UK have released some consensus guidelines on the treatment of neonatal jaundice.  In this podcast, we explore some of the literature relating to the care of jaundiced neonates.

Outline: Jaundice Treatment PEMcast

[CP]  intro, disclaimer

1 umol/L of bilirubin = 17.1 mg/dL

Honourable Mentions:
Maisels 2008
Hansen 2010

Exchange transfusion:

Mechanism, indications, risks, guidelines
[RR] bilitool.org quotes [AAP 2004 guidelines]
Risks of exchange transfusion: Jackson 1997
[KB] NICE CG 98 – threshold graphs in spreadsheet format

IV Ig evidence?

[RR] Alcock 2009 – Cochrane Review
[KB] Nasseri 2006 – not mentioned in Cochrane (not excluded, just ignored…probably due to language barrier, or repeat publication in 2009 without content update)

Albumin evidence?

[RR] Lack of evidence supporting use of Albumin for neonatal jaundice
Djokomuljanto 2006 – white curtains
Glacier analogy – free vs bound bilirubin (Hansen 2010)

Pharmacologic treatments on the horizon

[CP] Cuperus 2009
NICE CG 98 advises against multiple unproven therapies
Bili blanket not recommended for term babies (do not cover sufficient skin surface)

All: Summary, goodbye

Further Reading: The Papers that got away

Predicting Risk of Kernicterus: single SBR level?
(gestational age, genomic profile)
Ip 2004
Skae 2005
Ahlfors 2010

Early detection of EHBA (for early Kasai) improves outcome
Hsiao 2008 (stool colour card Taiwan)

Phototherapy: mechanism, light source, wavelength, etc
Maisels 2008
Hansen 2010
Djokomuljanto 2006 – white curtains

Breast-milk jaundice: what causes it, and is it entirely benign?
Gourley 2002
Gourley 2005

References

Maisels MJ, McDonagh AF.
Phototherapy for neonatal jaundice.
N Engl J Med. 2008 Feb 28;358(9):920-8. Review. PubMed PMID: 18305267.

Ruud Hansen TW.
Phototherapy for neonatal jaundice–therapeutic effects on more than one level?
Semin Perinatol. 2010 Jun;34(3):231-4. Review. PubMed PMID: 20494740.

American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.
Management of hyperbilirubinemia in the newborn infant 35 or more weeks of gestation.
Pediatrics. 2004 Jul;114(1):297-316. Erratum in: Pediatrics. 2004 Oct;114(4):1138. PubMed PMID: 15231951.

Jackson JC.
Adverse events associated with exchange transfusion in healthy and ill newborns.
Pediatrics. 1997 May;99(5):E7. PubMed PMID: 9113964.

National Institute for Health and Clinical Excellence
Clinical Guideline CG 98: Neonatal Jaundice
May 2010 http://www.nice.org.uk/CG98

Alcock GS, Liley H.
Immunoglobulin infusion for isoimmune haemolytic jaundice in neonates.
Cochrane Database Syst Rev. 2002;(3):CD003313. Review. PubMed PMID: 12137687.

Nasseri F, Mamouri GA, Babaei H.
Intravenous immunoglobulin in ABO and Rh hemolytic diseases of newborn.
Saudi Med J. 2006 Dec;27(12):1827-30. PubMed PMID: 17143357.

Djokomuljanto S, Quah BS, Surini Y, Noraida R, Ismail NZ, Hansen TW, Van Rostenberghe H.
Efficacy of phototherapy for neonatal jaundice is increased by the use of low-cost white reflecting curtains.
Arch Dis Child Fetal Neonatal Ed. 2006 Nov;91(6):F439-42. Epub 2006 Jul 28. PubMed PMID: 16877479.

Cuperus FJ, Hafkamp AM, Hulzebos CV, Verkade HJ.
Pharmacological therapies for unconjugated hyperbilirubinemia.
Curr Pharm Des. 2009;15(25):2927-38. Review. PubMed PMID: 19754369.

---

Ip S, Chung M, Kulig J, O’Brien R, Sege R, Glicken S, Maisels MJ, Lau J; American Academy of Pediatrics Subcommittee on Hyperbilirubinemia.
An evidence-based review of important issues concerning neonatal hyperbilirubinemia.
Pediatrics. 2004 Jul;114(1):e130-53. Review. PubMed PMID: 15231986.

Skae MS, Moise J, Clarke P.
Is current management of neonatal jaundice evidence based?
Arch Dis Child Fetal Neonatal Ed. 2005 Nov;90(6):F540. PubMed PMID: 16244219.

Ahlfors CE.
Predicting bilirubin neurotoxicity in jaundiced newborns.
Curr Opin Pediatr. 2010 Apr;22(2):129-33. Review. PubMed PMID: 20125026.

Hsiao CH, Chang MH, Chen HL, Lee HC, Wu TC, Lin CC, Yang YJ, Chen AC, Tiao MM, Lau BH, Chu CH, Lai MW; Taiwan Infant Stool Color Card Study Group.
Universal screening for biliary atresia using an infant stool color card in Taiwan.
Hepatology. 2008 Apr;47(4):1233-40. PubMed PMID: 18306391.

Gourley GR.
Breast-feeding, neonatal jaundice and kernicterus.
Semin Neonatol. 2002 Apr;7(2):135-41. Review. PubMed PMID: 12208098.

Gourley GR, Li Z, Kreamer BL, Kosorok MR.
A controlled, randomized, double-blind trial of prophylaxis against jaundice among breastfed newborns.
Pediatrics. 2005 Aug;116(2):385-91. PubMed PMID: 16061593.

It takes a long time and a lot of exposure to become comfortable with jaundiced newborns. Maybe we just become less cautious or less thorough over time… Most of us feel the need to slow down and consider all the possibilities, before jumping to a benign diagnosis.

Hopefully this little review will help you remember some of the basics of neonatal jaundice.
[drawing by Charlotte Parker, medium: etchysketch, yellow colouring shopped in by her dad]

Outline:Jaundice PEMcast

[CP] – intro, disclaimer.
Epidemiology:
Up to 60% of term and 80% or prem neonates become clinically jaundiced during the first week of life. Most resolve within 2 weeks and remain well throughout and require no treatment or intervention.

[KB] – Physiology:

[RR] – Kernicterus:

Literally means ‘yellow kern’ indicating the brain staining seen at autopsy. Was reducing but some reports suggest increasing incidence. Likely to be due to earlier discharges from hospital.

Bilirubin-induced neurologic dysfunction (BIND) is the term applied to the spectrum of neurologic abnormalities associated with hyperbilirubinemia.

[KB] – causes – by pathology:

Haemolysis – unconjugated:
Normal in neonates after Day 2

• Breakdown of Hb
• Immature liver
• Slow gut transit
• Bruising from delivery eg cephalohaematoma

Abnormal haemolysis:

• Blood group incompatibility
• G6PD deficiency
• Hereditary Spherocytosis
• SCD/Thallasaemia

Miscellaneous unconjugated causes:

• Sepsis
• Dehydration
• Hypothyroidism
• Trisomy 21

Conjugated Causes – always pathological:

• Biliary Atresia
• Hepatitis
• Genetic disorders
  • α1 AT deficiency
  • CF
  • Galactosaemia
  • Wilsons disease
  • Allagilles syndrome

[RR] – causes – by time line:

Day 1- Pathological
• Blood Group incompatibility

Day 2 – Day 14
• Normal physiological jaundice
• Sepsis
• All other causes listed above

> 14 days

• Unconjugated
  • Hypothyroidism
  • Abnormal haemolysis
  • Sepsis
  • Breast milk jaundice – diagnosis of exclusion
• Conjugated
  • as above

[CP] – causes – old school classification:
Pre-hepatic
Hepatic
Post hepatic

[KB] – important features of history:
Maternal hx
Risk factors
Timing
Feeding
Weight gain
Alertness
Stool and urine colour

[CP] – examination:
General appearance
Kramer’s rule
Bruising
Plethora
Temp instability
Hepatosplenomegly
Stool colour

[RR] – investigations:
Depend on timing and wellness of neonate, may include:
Split bilirubin (conjugated & unconjugated)
LFTs
U&E
FBC
TFT
G6PD
Urine reducing substances
Blood group and DCT
Urine MC+S +/- full septic screen
Maternal TORCH screening

[KB] – treatment
Depends on underlying cause
Well baby, mild jaundice – reassurance and monitoring
Unwell neonate – sepsis protocol
Significantly elevated unconjugated bilirubin – phototherapy / exchange transfusion / IV-Ig
Conjugated – further investigation of cause, and definitive treatment as required

[All] Goodbye, thanks for listening

Excluding a broken neck or a spinal cord injury: can be tricky. We know what to do when there is an obvious bony, ligamentous or cord injury… but do you want to be the one who takes responsibility to give the ‘all clear’?

Fortunately, serious injuries to the cervical spine, whether bony, ligamentous, or spinal cord injury, are uncommon in the really young… which is lucky for us, because these youngsters are also more difficult to assess – some clinicians feel uncomfortable trying to apply the NEXUS decision instrument in the under 3 year old age group. What evidence is out there, to guide our actions, for these children in our Emergency Departments and Intensive Care Units? Let’s try to weasel it out:

PEMcast Outline: Clearing the C-Spine

[CP/all] welcome, intro, disclaimer

[CP] Hoffman 2000: NEXUS

[CP] Canadian C-spine Rule 2001 (briefly) (& 2003 CCR vs NEXUS)

[KB] Viccellio 2001

[KB] McCarthy & Oakley 2002 (briefly)

[CP] Gary Browne 2003 CHW – use of adult protocols for kids?

[CP] Slack 2004 (briefly)

[KW] American Association Surgeons Trauma:  J Trauma 2009

[KB] Hutchings 2009 Review J Trauma

[CP] Hutchings 2009 J Trauma “protocol” (retrospective review)

[KW] Anderson 2010 March J Neurosurg Ped – protocol retrospective review

[CP] Kreykes 2010 November – review

[ALL] Summary, personal perspective, Goodbye

References

Hoffman JR, Mower WR, Wolfson AB, Todd KH, Zucker MI.
Validity of a set of clinical criteria to rule out injury to the cervical spine in patients with blunt
trauma. National Emergency X-Radiography Utilization Study Group.
N Engl J Med. 2000 Jul 13;343(2):94-9. Erratum in: N Engl J Med 2001 Feb 8;344(6):464. PubMed
PMID: 10891516.

Stiell IG, Wells GA, Vandemheen KL, Clement CM, Lesiuk H, De Maio VJ, Laupacis
A, Schull M, McKnight RD, Verbeek R, Brison R, Cass D, Dreyer J, Eisenhauer MA,
Greenberg GH, MacPhail I, Morrison L, Reardon M, Worthington J.
The Canadian C-spine rule for radiography in alert and stable trauma patients.
JAMA. 2001 Oct 17;286(15):1841-8. PubMed PMID: 11597285.

Stiell IG, Clement CM, McKnight RD, Brison R, Schull MJ, Rowe BH, Worthington
JR, Eisenhauer MA, Cass D, Greenberg G, MacPhail I, Dreyer J, Lee JS, Bandiera G,
Reardon M, Holroyd B, Lesiuk H, Wells GA.
The Canadian C-spine rule versus the NEXUS low-risk criteria in patients with trauma.
N Engl J Med. 2003 Dec 25;349(26):2510-8. PubMed PMID: 14695411.

Viccellio P, Simon H, Pressman BD, Shah MN, Mower WR, Hoffman JR; NEXUS Group.
A prospective multicenter study of cervical spine injury in children.
Pediatrics. 2001 Aug;108(2):E20. PubMed PMID: 11483830.

McCarthy C, Oakley E.
Management of suspected cervical spine injuries–the paediatric perspective.
Accid Emerg Nurs. 2002 Jul;10(3):163-9. PubMed PMID: 12443038.

Browne GJ, Lam LT, Barker RA.
The usefulness of a modified adult protocol for  the clearance of paediatric cervical spine injury in the emergency department.
Emerg Med (Fremantle). 2003 Apr;15(2):133-42. PubMed PMID: 12675623.

Slack SE, Clancy MJ.
Clearing the cervical spine of paediatric trauma patients.
Emerg Med J. 2004 Mar;21(2):189-93. Review. PubMed PMID: 14988345.

Pieretti-Vanmarcke R, Velmahos GC, Nance ML, Islam S, Falcone RA Jr, Wales PW, Brown RL, Gaines BA, McKenna C, Moore FO, Goslar PW, Inaba K, Barmparas G, Scaife ER, Metzger RR, Brockmeyer DL, Upperman JS, Estrada J, Lanning DA, Rasmussen SK, Danielson PD, Hirsh MP, Consani HF, Stylianos S, Pineda C, Norwood SH, Bruch SW, Drongowski R, Barraco RD, Pasquale MD, Hussain F, Hirsch EF, McNeely PD, Fallat ME, Foley DS, Iocono JA, Bennett HM, Waxman K, Kam K, Bakhos L, Petrovick L, Chang Y, Masiakos PT.
Clinical clearance of the cervical spine in blunt trauma patients younger than 3 years: a multi-center study of the American Association for the Surgery of Trauma.
J Trauma. 2009 Sep;67(3):543-9; discussion 549-50. PubMed PMID: 19741398.

Hutchings L, Willett K.
Cervical spine clearance in pediatric trauma: a review of current literature.
J Trauma. 2009 Oct;67(4):687-91. Review. PubMed PMID: 19820571.

Hutchings L, Atijosan O, Burgess C, Willett K.
Developing a spinal clearance protocol for unconscious pediatric trauma patients.
J Trauma. 2009 Oct;67(4):681-6. PubMed PMID: 19820570.

Anderson RC, Kan P, Vanaman M, Rubsam J, Hansen KW, Scaife ER, Brockmeyer DL.
Utility of a cervical spine clearance protocol after trauma in children between 0 and 3 years of age.
J Neurosurg Pediatr. 2010 Mar;5(3):292-6. PubMed PMID: 20192648.

Kreykes NS, Letton RW Jr.
Current issues in the diagnosis of pediatric cervical spine injury.
Semin Pediatr Surg. 2010 Nov;19(4):257-64. Review. PubMed PMID: 20889081.

Neck Injuries in kids are fortunately quite uncommon, but the assessment of a child with a potential cervical spine injury remains stressful and challenging.  No-one wants to miss a broken neck… Because of the anatomical, physiological and behavioural differences, we can’t just do what we do for adults either.

How common is SCIWORA? How aggressively do we need to apply immobilisation and spinal boards? What does it mean to ‘clear’ the C-Spine? And who needs an X-Ray? Hop on board as we try to answer these tricky little questions…

PEMcast outline: C-Spine Assessment

[CP] Welcome, introductions (incl KW Adult trauma experience), disclaimer

[CP] Intro – incidence, structures that get damaged

[KW] SCIWORA – commoner in kids? Pang & Wilberger 1982

[KB] “Clearance” – what does it mean?

[CP] Resuscitation / life threats first

[KW] Immobilisation: who? How? Spinal boards…

[KB] analgesia options (& tips)

[CP] History esp mechanism of injury

[KW] Examination (ABCDE, Neuro, Musculoskeletal)

[KB] Who to image? NEXUS

[CP] Xrays & ?flexion-extension views

[KW] CT scan ?skip X-Rays, straight to CT if definitely need head CT?

[[KB] use of MRI

Assessing C-Spine X-Rays:
[CP] Adequacy & alignment (incl pseudo-subluxation reference Slack 2004 – confusing)
[KW] Bones & cartilage
[KB] Soft tissues – do you use 3/7/21mm etc?

[CP] removing the collar

[KW] “Clearing” the C-spine: Injury identified vs “all seems fine”

[KB] Ongoing suspicion & unconscious patients

[ALL] What about the very young patient? Pre-verbal, ‘uncooperative’, but lower risk of serious injury –
personal tips / strategies

[CP] RCH Melbourne CPG compared to PMH Guideline

[ALL] Summary, goodbye

References

Pang D, Wilberger JE Jr.
Spinal cord injury without radiographic abnormalities in children.
J Neurosurg. 1982 Jul;57(1):114-29. PubMed PMID: 7086488

Slack SE, Clancy MJ.
Clearing the cervical spine of paediatric trauma patients. Emerg Med J. 2004 Mar;21(2):189-93. Review. PubMed PMID: 14988345

There must be a combination of clinical features and/or tests that can help us figure out whether the limping child has a benign, self-limiting “irritable hip” or the scary and serious condition of pus in the joint: septic arthritis. It turns out that Dr Kocher has been working on this for years, and a few other investigators have worked at validating the results of the original 1999 study.

Our mission on this PEMcast is to make some sense of the clinical and laboratory factors that help us to risk stratify for Septic Arthritis. We delve into the literature, and give our synopsis of the few papers that address this important clinical dilemma… When should we get blood tests, and when can we safely reassure parents that watchful waiting is the best course of action?

Overview: Septic Arthritis PEMcast

[CP] BestBETs article (Taekema 2009)

Which refers to:

• Kocher 1999
• Jung 2003
• Kocher 2004
• Luhmann 2004
• Caird 2006

[KB] Kocher 1999

[CP] Jung 2003

[RR] Kocher 2004

[KB] Luhmann 2004

[CP] Caird 2006

[RR] Sultan 2010 JBJS – overview

[ALL] Bottom line, own experiences

[cp] Goodbye, thanks…

References

Taekema HC, Landham PR, Maconochie I.
Towards evidence based medicine for paediatricians. Distinguishing between transient synovitis and septic arthritis in the limping child: how useful are clinical prediction tools?
Arch Dis Child. 2009 Feb;94(2):167-8. Review. PubMed PMID: 19158141.

Kocher MS, Zurakowski D, Kasser JR.
Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm.
J Bone Joint Surg Am. 1999 Dec;81(12):1662-70. PubMed PMID: 10608376.

Jung ST, Rowe SM, Moon ES, Song EK, Yoon TR, Seo HY.
Significance of laboratory and radiologic findings for differentiating between septic arthritis and transient synovitis of the hip.
J Pediatr Orthop. 2003 May-Jun;23(3):368-72. PubMed PMID: 12724602.

Kocher MS, Mandiga R, Zurakowski D, Barnewolt C, Kasser JR.
Validation of a clinical prediction rule for the differentiation between septic arthritis and transient synovitis of the hip in children.
J Bone Joint Surg Am. 2004 Aug;86-A(8):1629-35. PubMed PMID: 15292409.

Luhmann SJ, Jones A, Schootman M, Gordon JE, Schoenecker PL, Luhmann JD.
Differentiation between septic arthritis and transient synovitis of the hip in children with clinical prediction algorithms.
J Bone Joint Surg Am. 2004 May;86-A(5):956-62. PubMed PMID: 15118038.

Caird MS, Flynn JM, Leung YL, Millman JE, D’Italia JG, Dormans JP.
Factors distinguishing septic arthritis from transient synovitis of the hip in children. A prospective study.
J Bone Joint Surg Am. 2006 Jun;88(6):1251-7. PubMed PMID: 16757758.

Sultan J, Hughes PJ.
Septic arthritis or transient synovitis of the hip in children: the value of clinical prediction algorithms.
J Bone Joint Surg Br. 2010 Sep;92(9):1289-93. PubMed PMID: 20798450.

Watchful waiting or invasive investigations?  A limping child may have transient synovitis, or something more serious such as septic arthritis, osteomyelitis, or Perthes Disease.

Tests can be falsely reassuring in the early stages… Join us for a tour of clinical discovery in evaluating the child with a limp.

Outline: Limping Child PEMcast

[cp] Hello, welcome, introductions, disclaimer

[cp] Background / incidence / importance of ED role

[cp] Limping Child: non-ED setting

Roberts 2009 –
[cp] quick overview
[RR] Gait abnormalities (in brief)
[KB] Major differential diagnoses

[cp] ED setting: Limp associated with pain / discomfort:
Differentials: hip / limb / other:
[KB] Limb: foot / toe / shin / knee/ thigh / hip (“pebble in the shoe”)
[cp] Other: referred from spine / abdomen (appendicitis) / genitalia (torsion) / retroperitoneal
[RR] Hip (most common subset):
SA
OM
TS
Reactive arthritis
JIA = JRA = JCA
Perthes Disease
SCFE
Trauma (including NAI)
Neoplasia

[cp] Don’t be a Boob…

•Trauma
•Infection
•Tumour

History of recent trauma always present & often blamed, think of other causes…

Assessment:

[KB] History:
Trauma (&context) vs gradual onset
Recent illness
Fever
Systemic symptoms
Rash (Still’s Disease = SOJIA;  HSP)
Mobility (weight-bearing/crawling)

[RR] Examination:
Observation, Fever, General appearance
Gait
Back & pelvis
Genitalia
Limb starting at foot
Heel Percussion (or even push & twist)
Joints (look, feel, move)
Hip flexion, external  & INTERNAL rotation

Specific conditions:

[KB] Perthe’s Disease
•Avascular necrosis of femoral head
•Cause is not known
•4-10 years age, boys > girls
•Uncommon but potentially BAD
•Diagnosed on X-ray
•Refer to Orthopaedics
•May need operation

[cp] SCFE
•Slipped Capital Femoral Epiphysis
= Slipped Upper Femoral Epiphysis (SUFE)
•Stress fracture through femoral growth plate
•10-15 years age group
•especially chubby boys
•Diagnosed on X-ray
•Refer to Orthopaedics
•Cannulated screw

[RR] Septic Arthritis
= pus in the hip joint
•Rare but BAD
•Difficult to exclude / confirm
May have:
•Fever (up to 80%), Rigors (20%), ‘toxic’ looking, unwell
•Muscle spasm / pseudoparalysis / decreased ROM
•­WCC, ­ESR, ­CRP
•U/S-guided aspiration of hip joint (in theatre):
•invasive, GA risks
•50-75% of clinically diagnosed SA have positive culture
•?Unlikely in well child if ultrasound shows effusion < 5 mm
•Treatment = washout in theatre, IV AB’s (after ortho ‘approval’***),
?IV dexamethasone (shorter recovery, fewer complications)

*** treating ‘blind’ without an organism diagnosis results in more complications, more procedures, longer duration of treatment, more frustration & anxiety for orthopaedic surgeons

[cp] Osteomyelitis
= pus in the bone
•Commonest around knee joint
•Distal femur > proximal tibia
•Can occur anywhere, including proximal femur
•Similar to septic arthritis in presentation
•Diagnosed on bone scan
•X-Ray changes take weeks to develop
•Treatment = IV AB’s for weeks

[KB] Transient Synovitis
•Inflammation ± fluid in joint capsule
•3-8 years peak age group (±recent viral infection)
•Commonest cause of limp in a young child
•Clinical diagnosis
“Capsular Pattern” = Limited internal rotation compared to the other side
[cp] (anatomy of hip joint)
•May need to do some tests to ‘risk stratify’ for other causes (Septic Arthritis)
eg Xray, U/S, FBC/ESR/CRP
Treatment:
•Self-limiting condition, 1-3 days
•Ibuprofen (quicker recovery than placebo) & paracetamol (acetaminophen)
•GP review (or return to ED if worse)
•Follow-up
? Repeat Ultrasound in 3-4 weeks (Perthes 10%)

[RR]>> Challenges for us in ED:
•not to ‘miss’ Septic Arthritis
•not to over-investigate those with benign condition of Transient Synovitis (“what’s the next test?”)
•not to close the door on other possibilities (open mind)

[cp] Risk stratifying SA vs TS is difficult, requires good thorough clinical assessment, collaboration with caregivers.
Tests have limited utility (especially blood tests in first day or two – can be falsely reassuring)

Protocols and flowcharts:
eg septic vs trauma vs other causes
Lower threshold for tests in younger children?

[all] Goodbye… send us a comment (or a tweet)

Most children with a minor head injury (GCS 14-15) have an excellent prognosis, but a small number will deteriorate unexpectedly, and go on to require neurosurgical intervention.  The last decade has seen valiant attempts at trying to define and predict this subgroup of kids who need a cranial CT, to pre-empt this deterioration.

Clinical Decision Rules seem to be the fashion when it comes to making the risk-benefit analysis in high-volume clinical conditions with a small risk of a bad outcome, but how useful are these in everyday Paediatric Emergency Medicine practice? Join us for a discussion and comparison of your favourite head CT decision instruments… Canadian, CHALICE, NICE, PECARN, CATCH – we’ve got ‘em all!

Outline: Cranial CT for MHI PEMcast

[CP] Welcome, disclaimer, intro

Traditional approach – observation, selected CT, limited evidence base
Pressures of cost and litigation
Increasing use of CT in North America – risks – XRayrisk.com
Cognitive impairment (Scandinavian studies – Hall BMJ 2004)
Consent for radiation (and contrast) and General Anaesthetic

Problem is identifying the child at risk for intracranial injury without clinical signs of intracranial injury at time of assessment (vs identifying low-risk children who do not need CT)

Ideal tool would use clinical features (ie non-invasive) in history & examination to risk stratify for intracranial injury – ie high NPV for low-risk, high PPV for high risk, with a good balance between sensitivity and specificity (ROC curve).
Also, easy to remember, prospectively validated in population of interest.

Population is important – any test looks good when prevalence of bad outcome is very low (or very high). Clinical prediction rules most helpful in situations where clinician is not sure… or to justify with science your intuitive risk assessment.

So, what combination of clinical features is useful in predicting risk?

Papers: Decision Rules

[CP] [Canadian CT Head 2001 = adults]

[KR] Palchak 2003 Annals Emerg Med

[KB] Dunning 2006 – CHALICE

[CP] Maguire 2009 Systematic Review

[KR] PECARN (Kupperman 2009 Lancet)

[CP] CATCH (Osmond 2010 CMAJ)

[KB] Pickering 2011 Systematic Review

Guidelines

[CP] [NICE 2003 = Canadian CT head mostly]

[KR] NICE  Guideline 2007

[KB] RCH Head Injury CPG

[CP] Starship

[KR] PMH – focus on minor head injury

[KB] PMH – return to sport advice

[CP] PREDICT (MB personal communication) survey findings
-plan to prospectively compare all rules

[ALL] Clinical bottom line, tips, personal experience

[CP] Summary, goodbye

References

Hall P, Adami HO, Trichopoulos D, Pedersen NL, Lagiou P, Ekbom A, Ingvar M, Lundell M, Granath F. Effect of low doses of ionising radiation in infancy on cognitive function in adulthood: Swedish population based cohort study. BMJ. 2004 Jan 3;328(7430):19. PubMed PMID: 14703539

Stiell IG, Wells GA, Vandemheen K, Clement C, Lesiuk H, Laupacis A, McKnight RD, Verbeek R, Brison R, Cass D, Eisenhauer ME, Greenberg G, Worthington J. The Canadian CT Head Rule for patients with minor head injury. Lancet. 2001 May 5;357(9266):1391-6. PubMed PMID: 11356436.

Palchak MJ, Holmes JF, Vance CW, Gelber RE, Schauer BA, Harrison MJ, Willis-Shore J, Wootton-Gorges SL, Derlet RW, Kuppermann N. A decision rule for identifying children at low risk for brain injuries after blunt head trauma. Ann Emerg Med. 2003 Oct;42(4):492-506. PubMed PMID: 14520320.

Dunning J, Daly JP, Lomas JP, Lecky F, Batchelor J, Mackway-Jones K; Children’s head injury algorithm for the prediction of important clinical events study group. Derivation of the children’s head injury algorithm for the prediction of important clinical events decision rule for head injury in children. Arch Dis Child. 2006 Nov;91(11):885-91. PubMed PMID: 17056862.

Maguire JL, Boutis K, Uleryk EM, Laupacis A, Parkin PC. Should a head-injured child receive a head CT scan? A systematic review of clinical prediction rules. Pediatrics. 2009 Jul;124(1):e145-54. Review. PubMed PMID: 19564261.

Kuppermann N, Holmes JF, Dayan PS, Hoyle JD Jr, Atabaki SM, Holubkov R, Nadel FM, Monroe D, Stanley RM, Borgialli DA, Badawy MK, Schunk JE, Quayle KS, Mahajan P,Lichenstein R, Lillis KA, Tunik MG, Jacobs ES, Callahan JM, Gorelick MH, Glass TF, Lee LK, Bachman MC, Cooper A, Powell EC, Gerardi MJ, Melville KA, Muizelaar JP, Wisner DH, Zuspan SJ, Dean JM, Wootton-Gorges SL; Pediatric Emergency Care Applied Research Network (PECARN). Identification of children at very low risk of clinically-important brain injuries after head trauma: a prospective cohort study. Lancet. 2009 Oct 3;374(9696):1160-70. Epub 2009 Sep 14. PubMed PMID: 19758692.

Osmond MH, Klassen TP, Wells GA, Correll R, Jarvis A, Joubert G, Bailey B, Chauvin-Kimoff L, Pusic M, McConnell D, Nijssen-Jordan C, Silver N, Taylor B, Stiell IG; Pediatric Emergency Research Canada (PERC) Head Injury Study Group. CATCH: a clinical decision rule for the use of computed tomography in children with minor head injury. CMAJ. 2010 Mar 9;182(4):341-8. Epub 2010 Feb 8. PubMed PMID: 20142371

Pickering A, Harnan S, Fitzgerald P, Pandor A, Goodacre S. Clinical decision rules for children with minor head injury: a systematic review. Arch Dis Child. 2011 Feb 10. [Epub ahead of print] PubMed PMID: 21310894.

A little bump on the head… could cause a lot of trouble for you and me. Minor Head Injury used to mean GCS 13-15, nowadays it means GCS 14-15. This is the vast majority of head injury cases, and therefore we need to be really comfortable with their assessment and management.

Plug in and join us as we discover the origins of the 4-hour myth, the creative definition of concussion, and the correct use of the vomitometer…

Outline of the MHI PEMcast

[CP] Welcome, disclaimer, intro

Definition: GCS =14-15

Epidemiology (common, with serious sequelae uncommon)

Severe head injury discussed previously on D is for disability PEMcast (part 2)

Problem is identifying the child at risk for intracranial injury without clinical signs at time of assessment (vs identifying low-risk children who do not need CT)

Strategies include observation or investigation (head CT) or combination.

Assessment of Child with Minor Head Injury

[CP] Initial ‘eyeball’ – appearance, vital signs, ABCD

[KR] History

Past Medical History / background
Mechanism
Cause of injury (fall vs collapse vs NAI)
Loss of Consciousness (duration) – difficult to estimate
Seizure
Vomiting (lower threshold in children)
Headache
Behaviour

[KB] Examination

General
CNS: AVPU, pupils, activity, cerebellar, motor, sensory
GCS vs PGCS (discussed in D for Disability PEMcast)
Head: skin /scalp, Signs of BOS#
Higher functions: mental slowness
[CP] (DLROW, serial 3’s, days of week backwards)

Management of Child with MHI

Analgesia
?anti-emetics (probably not)
Observation – how long?
4 hour myth origins
Rectal or IM Caffeine? (1954 paper: Pickles)

Imaging

[KR] SXR – who? (infants, NAI, FB)

[KB] CT scan

Risks (radiation, cognitive, GA risk)
Costs
Implications of abnormal scan:
CT visible lesion vs lesion requiring neurosurgical intervention
Do we need to detect non-surgical abnormalities?

Concussion

[CP] Definition?

What to expect
Sport and return to sport

[KR] Discharge advice – safety net
Verbal vs written

[ALL] Clinical bottom line, tips, personal experience

[CP] Summary, goodbye, see you next time, when we get seriously evidence-heavy with CT decision rules…

PICKLES W, McOSKER TC. Head injuries in children. Pediatr Clin North Am. 1954 Nov:787-99. PubMed PMID: 13204073.

We like to think we practice evidence-informed medicine… but what evidence do we have that these medications work in acute asthma? Inhaled treatments make sense, and we can see them working right before our eyes, but when things get serious, response to more aggressive interventions don’t seem to be quite as convincing.

We have hand-picked a few papers to show the way, in terms of backing up the use of Magnesium, Ipratropium, Aminophylline, and IV Salbutamol (albuterol).  Join us as we skip joyfully through some evidence from the last few years.

Evidence base for drug treatments in Acute Asthma

CP: welcome, disclaimer

CP: variability of practice (Bianchi 2010, variable ED cultures)

SF: Ipratropium (Munro 2006 and Rodrigo 2005, EMMA study)

KB: Aminophylline (Mitra 2005 = Cochrane, which included Yung 1998 = RCH Melbourne)

SF: Magnesium (Markovitz 2002 bestBET, Rowe 2008)

CP: Salbutamol IV (evidence vs inhaled/nebs, adverse effects, dosing rationale):

Lawford 1978
Salmeron 1994
Browne 1997
Browne 2002

All/CP: Personal experiences, summary, goodbye

References

Bianchi M, Clavenna A, Bonati M. Inter-country variations in anti-asthmatic
drug prescriptions for children. Systematic review of studies published during
the 2000-2009 period. Eur J Clin Pharmacol. 2010 Sep;66(9):929-36. Epub 2010 Jun 9. Review. PubMed PMID: 20533030.

Munro A, Maconochie I. Best evidence topic reports. Beta-agonists with or
without anti-cholinergics in the treatment of acute childhood asthma? Emerg Med J. 2006 Jun;23(6):470. Review. PubMed PMID: 16714513; PubMed Central PMCID: PMC2564349.

Rodrigo GJ, Castro-Rodriguez JA. Anticholinergics in the treatment of children
and adults with acute asthma: a systematic review with meta-analysis. Thorax.
2005 Sep;60(9):740-6. Epub 2005 Jul 29. Review. Erratum in: Thorax. 2006 May;61(5):458. Thorax. 2010 Dec;65(12):1118. Thorax. 2006 Mar;61(3):274. Thorax. 2008 Nov;63(11):1029. PubMed PMID: 16055613; PubMed Central PMCID: PMC1747524.

Mitra A, Bassler D, Goodman K, Lasserson TJ, Ducharme FM. Intravenous aminophylline for acute severe asthma in children over two years receiving
inhaled bronchodilators. Cochrane Database Syst Rev. 2005 Apr 18;(2):CD001276. Review. PubMed PMID: 15846615.

Yung M, South M. Randomised controlled trial of aminophylline for severe acute
asthma. Arch Dis Child. 1998 Nov;79(5):405-10. PubMed PMID: 10193252; PubMed Central PMCID: PMC1717748.

Markovitz B. Does magnesium sulphate have a role in the management of paediatric status asthmaticus? Arch Dis Child. 2002 May;86(5):381-2. Review.
PubMed PMID: 11970943; PubMed Central PMCID: PMC1751095.

Rowe BH, Camargo CA Jr. The role of magnesium sulfate in the acute and chronic management of asthma. Curr Opin Pulm Med. 2008 Jan;14(1):70-6. Review. PubMed PMID: 18043278.

Lawford P, Jones BJ, Milledge JS. Comparison of intravenous and nebulised salbutamol in initial treatment of severe asthma. Br Med J. 1978 Jan 14;1(6105):84. PubMed PMID: 339993; PubMed Central PMCID: PMC1602586.

Salmeron S, Brochard L, Mal H, Tenaillon A, Henry-Amar M, Renon D, Duroux P, Simonneau G. Nebulized versus intravenous albuterol in hypercapnic acute asthma. A multicenter, double-blind, randomized study. Am J Respir Crit Care Med. 1994 Jun;149(6):1466-70. PubMed PMID: 8004299.

Browne GJ, Penna AS, Phung X, Soo M. Randomised trial of intravenous salbutamol in early management of acute severe asthma in children. Lancet. 1997 Feb 1;349(9048):301-5. PubMed PMID: 9024371.

Browne GJ, Trieu L, Van Asperen P. 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. Crit Care Med. 2002 Feb;30(2):448-53. PubMed PMID: 11889328.

Asthma in kids is common… very common.  So we should know how to manage it in our Emergency Departments.  Occasionally we see a child with severe or critical asthma; when this happens it is useful to know what your plan is – a plan you can make beforehand, rather than in the heat of the moment…

Join us for this PEMcast as we navigate the current conventional wisdom on management of acute asthma, including what to do when things are not going as well as you would have liked…

Outline of this podcast: Asthma

CP: welcome, disclaimer

CP: intro (not discussing diagnostic controversies in infants & toddlers)

SF: definition (recurrent reversible wheeze?)

KB: incidence (worldwide vs WA – seems high in Perth)

CP: chronic stable asthma assessment & management

SF: assessment of acute asthma attack – overview (Asthma Management Handbook pg 43-46 – table 5)

KB: signs of severe / critical asthma

CP: put into context of treatment prior to attending ED

SF: management of mild & moderate: salbutamol (=albuterol), review response (is fall in SpO2 always bad?), decide disposition

CP/all: why spacers, not nebs?

All: Who should get steroids? What dose? How long? (controversy of steroids in under 5′s to be discussed another time)

KB: treatment options in severe / critical asthma (Atrovent, IV salbutamol, aminophylline, magnesium, mechanical ventilation)

All: any advantage of Adrenaline (=epinephrine) neb, IM or IV)?

CP: Non-Invasive Ventilation vs Intubation & IPPV (risks/complications)

All: Options for intubating drugs (midazolam, fentanyl, thiopentone, propofol, ketamine, muscle relaxant)

SF: Initial ventilator settings

CP/all: Resources (NAC, RCH asthma action plan generator), Summary, goodbye for now

Appendicitis is the most common surgical condition in children, and an important condition not to miss.  Can we use clinical features, scoring systems, blood tests or radiological investigations to improve our diagnostic accuracy?

In this episode we put the diagnostic process under the microscope and try to figure out the most helpful symptoms, signs and tests to confirm or exclude appendicitis.

Outline: Tests for Appendicitis

[CP] hello, disclaimer, introduction

Review Article:

Bundy 2007 JAMA

Bundy DG, Byerley JS, Liles EA, Perrin EM, Katznelson J, Rice HE.
Does this child have appendicitis? JAMA. 2007; 298(4):438-51. Review. PubMed PMID:17652298

[CP] overview (including methods)

[KB] appendicitis symptoms

[SF] appendicitis signs

[CP] results: symptoms

[KB] results: signs

[SF] results: WBC count & differential

[CP] results: CRP & ESR

[ALL] comments re blood tests especially WBC

Passing mention of O’Shea 1988 Pediatric Emergency Care

[CP] Scoring systems: Alvarado Score (still with reference to Bundy)

[CP] Alvarado 1986 Annals of Emergency Medicine

[SF] Scoring sytems: (Samuel) Paediatric Appendicitis Score (still with reference to Bundy)

[SF] Samuel 2002 J Pediatric Surgery

[KB] Scoring systems: Low-Risk decision rule: (with reference to Bundy)

[KB] Kharbanda 2005 Pediatrics

Passing mention of Schneider 2007 (Annals of Emergency Medicine) prospective evaluation of scoring systems (still with reference to Bundy):

[SF] Clinical gestalt (as indicated by imaging ordered)

[CP] Comparison with Adult data

[KB] Limitations in the Literature

Imaging Tests for suspected appendicitis

[CP] introduction (rule-out vs rule-in strategies, unnecessary when diagnosis obviously appendicitis or obviously not)

[KB] UltraSound with Graded Compression – Sim 1989 J National Med Association

[SF] CT for Appendicitis: Callahan 2002 Radiology

[CP] Contrast or not: Kaiser 2004 Radiology

[SF] An Argument for Ultrasound: Strouse 2010 Radiology

[KB] Routine Ultrasound & Limited CT: Toorenvliet 2010 World J Surgery

[ALL] Comments re: Imaging in suspected appendicitis
(where does Australia sit on the UK – USA spectrum – U/S vs CT?)

What’s new?

[SF] calprotectin (S100A8/A9): Bealer & Colgin 2010 Academic Emergency Medicine – featured in Journal Watch top 10 most read articles in EM in 2010

Bottom Line

[KB] Acheson & Banerjee 2010 Arch Dis Child Education & Practice Edition

[ALL] When to do blood tests?

[ALL] When to get imaging?

[ALL] When to get Surgical review?

[ALL] Discharge advice – when appendicitis unlikely but not excluded

[CP] Summary, goodbye

ADHD Corner: Brief Synopsis

For those with short attention spans, here is the abridged version.

For those of you with short attention spans… here is the synopsis of our Appendicitis PEMcast.

Belly pain is a very common Paediatric ED presentation, so how do we sort the plain old tummy-ache from the more serious causes?  Common conditions like gastroenteritis and constipation can mimic more significant diagnoses such as appendicitis and intussusception.

In this PEMcast we take a quick tour through the causes of abdominal pain in children.
To listen, click below or subscribe via iTunes or RSS…

Outline: Abdominal Pain in Children

[CP] hello, disclaimer, introduction/background

Approach & Differentials

(with reference to McCollough & Sharieff 2006, and our own experience):

[KB] Approach to assessment

[SF] Extra-abdominal causes of belly pain:

• Infections:
  • pharyngitis / URTI = mesenteric adenitis
  • pneumonia
  • sepsis
• Toxins:
  • spider bite (probably not Red Back Spider)
  • ingestions eg iron
• Metabolic:
  • HUS
  • DKA
• Other:
  • HSP
  • abdominal migraine
  • abdominal epilepsy ??
  • functional
  • torsion testis / ovary

Tsalkidis A, Gardikis S, Cassimos D, Kambouri K, Tsalkidou E, Deftereos S, Chatzimichael A. Acute abdomen in children due to extra-abdominal causes. Pediatr Int. 2008 Jun;50(3):315-8. PubMed PMID: 18533944.

Causes of Abdominal Pain in Children

[CP] Main concern for parents and doctors is appendicitis (difficult diagnosis, medicolegal concerns, signifcant morbidity, high rate of perforation in younger children)

Other causes: (brief sketch of each):

[KB] Gastro

[SF] Constipation

[CP] Mesenteric adenitis

[KB] Functional & recurrent Abdo pain

[SF] Abdominal Migraine

[CP] Intussusception

[KB] Bowel Obstruction & incarcerated hernia

[SF] Meckel’s diverticulitis

[CP] Infants: “Colic”

(Pyloric spenosis, malrotation with midgut volvulus, NEC) – pain is not the predominant symptom

[ALL] Comments on abdo pain differentials, colic, infants & neonates

[CP] Summary, goodbye

Dex or Pred? What dose? Grandmaster G helps us navigate the steroid evolution of the last couple of decades. We’re almost there, just one big RCT until we know the answer!

To listen to this podcast, click on the media below, or subscribe using iTunes or another podcatcher. Feel free to share with your colleagues!

Steroids for Croup

Introduction & disclaimer
History – steroids introduction

[GG] initial disbelief in steroids for croup

[SF] Pred for intubated patients – Tibballs Lancet 1992

[CP] Geelhoed 1995 dex vs budesonide vs placebo

[CP] Geelhoed GC, Macdonald WB. 1995 0.6 vs 0.3 vs 0.15 (dose-finding)

[CP] Geelhoed 1996 (BMJ) dex 0.15 vs placebo for mild croup (outpatient)

[KB] Geelhoed 1996 (Annals Emerg Med): Sixteen years’ experience

[CP] Latest Cochrane review: Russell 2004 (Jan)
31 studies included, N=3736
Steroids work within 6 hrs and decrease admission, length of stay, return visits
Implications for research: optimal dose dex needs to be defined (0.15 vs 0.6); dissemination of evidence / physician uptake

[CP] PECARN Bjornson 2004 (Sept)
dex 0.6mg/kg vs placebo! N=720
Representation rate halved from 15 to 7 percent, less stress for parents

Pred vs Dex papers

[SF] Sparrow  2005 (n=133)

[KB] Alison Fifoot & Joseph Ting EMA 2007 (n=99)

[SF] 2009 Milana & Gary 27 yrs’ experience: progress paper

[CP] Dose of dex finally settled?
bestBET Port 2009
but Review in NEJM 2008 by James Cherry still recommends dex 0.6

[CP] Introduction to ToPDoG study
Aiming to recruit 3 x 437 subjects
Details on ANZCTR website

New directions

[KB] ?heliox

[SF] Coronavirus – a newly identified pathogen

[CP] ?paraflu vaccine

[all] Summary / pearls

[CP] Thanks to Gary

[all] Goodbye & Begood

You hear a barking cough, around midnight, and think: easy! But could it be one of the croup mimics? Croup is a potentially life-threatening upper airway obstruction that has a highly successful and satisfying treatment.

To listen to this PEMcast, click on the triangular play button below, or you can subscribe via your favourite podcatching software…

Outline of this Croup podcast

[CP] Epidemiology, Aetiology, Clinical manifestations & natural history
PIV 1,2,3  RSV  Rhinovirus  Enterovirus

[SF] Differentials of upper airway obstruction

[GG] ‘spasmodic’ croup (?does it exist)

[CP] Treatment = oral steroids, cuddle therapy

Pouseiulle-Hagen formula (gas flow in tubes):
R = 8ηL / π r 4

Turbulent flow (Reynolds’ number):
Re = density.Diameter.Velocity / viscosity

[CP] Treatments which don’t work: mist (Lavine 2001):

[GG] Unkind treatments: Inhaled /nebulised steroid (budesonide), IM/IV dex

[CP] Adrenaline for severe croup:
Duration of action (120min) Westley 1978
Dosing regimes (1% solution vs 1:1000 L-epinephrine) & confusion
HealthEngine article: Croup Guidance for Doctors

[CP] Borland 2008 – PREDICT current practice in Australasia

[All] Summary, goodbye, Happy New Year!

Three years ago the National Institute for Clinical Excellence in the UK released their guidance on the assessment and initial management of feverish illness in young children (CG47).  Most of the world outside of Britain has not been using this guidance, but we thought it would be useful to delve a bit deeper to see whether we could all benefit from the insights of their expert panel.

To listen to this podcast, click on the “Play” button below, or you can subscribe via iTunes using the link in the left column of this page.

Outline of this PEMcast

CP: Intro, hello, disclaimer

NICE CG47 Issued in May 2007, referenced in:

Richardson M, Lakhanpaul M; Guideline Development Group and the Technical Team.
Assessment and initial management of feverish illness in children younger than 5 years: summary of NICE guidance.
BMJ. 2007; 334: 1163-4

Richardson M, Lakhanpaul M.
Feverish illness in children under 5 years.
Arch Dis Child Educ Pract Ed. 2008; 93: 26-9

Main part of discussion centres around NICE CG47 (Full Guideline) Section 4:
Clinical assessment of the child with fever

CP: 4.1 Introduction

SF: 4.2 Priorities in Clinical Assessment

KB: 4.3 Life-Threatening features of Illness in Children

CP: 4.4.1-4.4.2 Assessment of Risk of Serious Illness and Traffic Light system

KB: Traffic lights: green components

SF: Traffic lights: orange

CP: Traffic lights: red

All: comments & discussion on traffic light components

CP: 4.5 Non-Specific symptoms and signs of Serious Illness

Big sections:

SF: 4.5.1 General Symptoms and Signs

KB 4.5.2 Predictive Values of common Physiological Measurements

CP 4.5.3 Height and Duration of Fever

SF 4.5.4 Assessment of Dehydration

CP 4.6 Specific Serious Illnesses – not discussing (will discuss on future episodes though)

With reference to Quick Reference Guideline:

SF: Overview of care pathway – page 4

KB: Assessment – page 8

CP: Introduction to management remote vs normal doctor vs paediatrician

Perspective from position of:

• KB: remote assessment
• CP: non-paediatric doctor
• SF: paediatrician

Would you use the guideline, would you stick to it?
Would you feel protected if something went wrong?

CP/ All: Outcomes / impact of NICE CG47, discussion, perspective & experience from clinical experience.

CP/All: Summary

Goodbye, thanks, see you next time…

“Doc, he’s burnin’ up!”  Fever is probably the commonest presenting complaint we manage in Paediatric Emergency Departments.  The cause is usually an infection… but not always.  The infection is usually a benign, self-limiting viral illness… but not always.

Join us for this podcast as we tease out the facts from the fiction, the myths and the mystery.

To listen, just click on the ‘play’ triangle below, or you can subscribe via your podcatching software (such as iTunes).

Fever Basics (Fear and Tradition)

CP/all: welcome, disclaimer, hello, intro

Background:

CP: Physiology / theoretical survival advantage of fever

SF: Methods of measuring: core (rectal), tympanic (not under 6 months), oral, axillary, ‘forehead strips’, ‘feels hot to parents’
KB: Definition of a fever, significant ‘cutoff’ values eg depending on age (neonate, 1-3months, 3-24 or 36 months)

Causes of fever:

KB: infections (viral, bacterial, rickettsia, malaria, others ) central theme = benign viral vs serious bacterial
SF: haematological/ oncological (lymphoma, leukaemia, Wilms, Neuroblastoma, others)
CP: auto-immune/ chronic inflammation (JIA, SLE, etc)

Periodic fevers:

See:  Periodic Fever Syndrome
and Causes of Cyclical Fever in Children

KB: Familial Mediterranean Fever
SF: Cyclical Neutropaenia
CP: Hyper-IgD syndrome
KB: TNF-Receptor Associated Periodic Syndrome (TRAPS)
SF: PFAPA syndrome

CP: drug-induced fevers
KB: factitious / induced illness
SF: don’t forget Kawasaki Disease
CP: idiopathic fever?

CP: FWS vs PUO (2 weeks)

Risk Stratifying FWS (SBI vs benign viral illness)

CP: past strategies – risk minimisers vs test minimisers, use of WCC
Changing landscape post-Pneumococcal Conjugate Vaccine (following the US experience)
“Needle in a haystack” problem and the Ian Everitt corollary…

SF: factors to consider in risk-stratifying:

• age
• height of fever (or not)?
• clinical findings / source (incl “soft”/ co-existent signs like slightly red throat, pink TMs from fever itself)
• urine sampling in those without clear clinical focus

KB: “well” vs “unwell” – hard to define, hard to teach!

Can we forget about “Occult Bacteraemia” now?

Treatment of febrile illness

SF: treat underlying infection:

• clear source/focus: treat appropriately based on diagnosis and severity
• no focus but unwell: screen (LP, CXR, Urine, BC) admit, IV AB’s pending negative cultures
• well but FWS: follow-up strategy 12-24 hrs GP/ED, (+/- IM antibiotics, Blood cultures)- evolving

CP: supportive care: hydration, nutrition, observation, comfort

Antipyretics for comfort?

KB: arguments FOR antipyretics (feel better, look better, drink better, easier to assess clinically, placebo effect?)
SF: arguments AGAINST antipyretics (not natural – defence mechanism, medication side-effects – Reye Syndrome historically, ?wheeze from NSAIDs,  may prolong illness)

CP: physical cooling: methods (undressing, fan, tepid sponging, cool bath, “hydrotherapy”) benefits & risks

Fever Myths

CP: “Fever is Dangerous” (boiled brain)
SF: “Antipyretics prevent Febrile Convulsions”
KB: “Favourable Response to Antipyretics excludes Serious Bacterial Illness”
CP: “Social smile excludes Serious Illness”

Bass JW, Wittler RR, Weisse ME. Social smile and occult bacteremia. Pediatr Infect Dis J. 1996;15(6):541.
PubMed PMID: 8783353.

Advice to Parents on Discharge

CP: fever in perspective, supportive care, follow-up if necessary
All: specific reasons to return

CP/All: Summary

Goodbye for now Folks!
Next time, we will discuss: NICE Guideline CG47 – Feverish Illness in Children.
As always, we welcome your intelligent and insightful comments!

To bolus, or Not to bolus… that is the question.  Actually, there are a few more questions too… How low is too low? What are the causes of neonatal hypoglycaemia? Any advances in research?

Some neonatologists believe that a bolus of intravenous dextrose when treating hypoglycaemia is to be avoided at all costs.  Others say a bolus is OK, provided that an ongoing infusion at an adequate rate to maintain euglycaemia is instituted without delay.

Outline of this PEMcast

Controversies in Neonatal Hypoglycaemia

Including:

• definition
• when to treat asymptomatic hypoglycaemia
• how to treat

…with reference to a few papers and clinical practice guidelines.

Background:

[KB] 1999 Stanley (NEJM) – causes of hypoglycaemia
[CP] 2000 Cornblath (Pediatrics) – controversies with definition
[SF] 2004 McGowan (NeoReviews.org) – how low is too low?

Current Guidelines:

[CP] RCH Melbourne
[SF] Starship Children’s Hospital
[KB] KEMH

Last few years:

[SF ]2006 Rozance (Biology of the Neonate) – predicting adverse outcomes
[CP] 2008 Burns (Pediatrics) – patterns of brain injury
[SR] 2010 Straussman – current state of play

Discussion:

[al] Is our (local) guideline reflective of current evidence / knowledge?

[CP / SR] Summary & Conclusions

Exposure: getting a look at the whole patient, while preventing hypothermia.  It’s just part of being thorough, and thorough is Good.

Many have erred in the heat of the moment… it’s easy to get distracted by a sick-looking kid or a serious injury, but: Don’t Ever Forget Glucose!

On this episode we run through the meaning of “E”, and then move on swiftly to discuss hypoglycaemia and its treatment.

Outline of this PEMcast: EFG

[CP] Intro & disclaimer

Exposure

E is for exposure: complete examination of the whole child, whilst preventing hypothermia.

In trauma situation, refers to secondary survey, head-to-toe examination.

What can we discover with full exposure in the unwell / injured child:

[CP] Rash (urticaria = anaphylaxis/allergy, petechiae / purpura = ?meningococcaemia), fever/hypothermia

[KB] Occult injury – in obvious trauma patient, or in non-specifically unwell NAI victim – patterns of injury in NAI – in brief

[SF] Toxidromes (skin sweaty vs warm & dry, fasciculations, etc)

[CP] Causes of crying infant (hair tourniquet, clavicle fracture, corneal abrasion, etc)

DEFG: blood glucose

[KB] Normal physiology of maintaining blood glucose (glycogen stores, etc)

[SF] At what age can young children maintain their blood glucose during starvation?

[CP] Clinical manifestations of hypoglycaemia in children

-can be unexpected finding, can be overlooked, hence the need for reminders (DEFG, documentation on ED nursing record)

[KB] Causes of hypoglycaemia in children

[SF] Treatment – oral or IV glucose (?bolus),

[KB] find & treat cause

[SR] special endocrinologist tricks (glucagon, hydrocortisone, diazoxide, octreotide)

[all] Summary & goodbye

Please feel free to send us your comment, opinion, or money…

Severe Head Injury: is any treatment proven to work? Join us as we explore the literature behind currently accepted treatments for serious traumatic brain injury, in particular the role for therapeutic hypothermia.

Of all the things we do in the ED for severely head-injured children in the acute phase, the most important are probably to maintain oxygenation and perfusion of the brain.  The evidence base supporting other interventions is less clear, but these may still make sense from a pathophysiologic perspective.  Therapeutic hypothermia, in various forms, has been studied by a number of groups.  Sit back and relax, while we talk you through it…

D is for Disability: Advanced Topic: Therapeutic Hypothermia for TBI

First, we review some reviews on the current state of play for treatment of Traumatic Brain Injury (TBI).

Reviews

Moppett 2007

Traumatic brain injury: assessment, resuscitation and early management. IK Moppett.
British Journal of Anaesthesia 2007; 99: 18-31
30% patients admitted to hospital with GCS <13 ultimately die
For severe TBI, only 20% make good recovery (on GOS)
1/3rd who die will talk or obey commands before death, suggesting that initial injury per se is not lethal; secondary insults include ischaemia, re-perfusion, hypoxia
GCS discussed (Table of modifications with variable top score at different ages, P-GCS ?less sensitive to changes than adult score, reasonable intra- & inter-observer reliability, AVPU not been subjected to validation, categories correspond to Swedish Reaction Scale)
Hypotension: duration and number of episodes correlate with mortality
Hypoxia: less strong association, maybe less important for children
CO2: hypercapnea more common with multiple trauma, aggressive hyperventilation worsens outcome (<30mmHg = 4kPa)

Guidelines for BP, oxygenation and CO2 differ (USA=BTF, Europe=EBIC, UK=AAGBI)
Cochrane review – no evidence to support use of mannitol
Early (pre-hospital) intubation – conflicting results, possibly harmful
Tight glycaemic control risky and No benefit (mortality & 6-month outcome)
Spinal injury more likely as severity of head injury increases – CT neck when scanning head
Seizures increase metabolic rate and raise ICP, Phenytoin (& CMZ) decrease risk of early seizures (but not mortality or long-term seizures)

Pharmacologic treatments disappointing (Calcium channel blockers, Mg, amino-steroids/lazaroids, dexanabinol, high-dose steroids – increased mortality via unclear mechanism – not infection or GI bleeding)

Orliaguet 2008

Management of critically ill children with traumatic brain injury. Orliaguet GA, Meyer PG, Baugnon T.
Pediatric Anesthesia 2008; 18: 455-461

Walker 2009

Modern approaches to pediatric brain injury therapy.  Walker PA, et al.
Journal of Trauma 2009; 67: S120-S127

TBI-Hypothermia Papers

Let’s go back in time, to when it all started… Then we’ll skip forward to the last decade or so.

Hendrick 1959

The use of hypothermia in severe head injuries in childhood. E Bruce Hendrick.
Archives of Surgery 1959; 79: 362-364
Beneficial effects of reducing body temperature on the brain, decreased cerebral oedema and increased ability to resist hypoxia

Ice-packs to trunk, cooled to 31-32 (improved vital signs noted), if improving or static after 72hrs, gradually rewarmed to 35.
Re-cooled if deterioration on rewarming, average 13 days (3-35 days)
18 decerebrate cases with severe TBI
10 survivors, 4 normal, no vegetative or institutional care patients.

Marion 1997

The treatment of traumatic brain injury with moderate hypothermia.  Marion DW, et al.
The New England Journal of Medicine 1997; 336: 540-546
RCT 82 patients GCS 3-7 (=severe closed head injury)
Cooled to 33, 10 hrs after injury, for 24hrs only
Improved outcomes at 3 months and 6 months (risk 0.2 for bad outcome), only for subgroup with GCS 5-7, not at 12 months
Probably not cooled soon, cold or long enough.

Shann 2003

Hypothermia for traumatic brain injury: how soon, how cold, and how long? Shann F
The Lancet 2003; 362: 1950-1951

Hutchison 2008

Hypothermia therapy after traumatic brain injury in children.  Hutchison JS, et al.
The New England Journal of Medicine 2008; 358: 2447-2456

Taylor 2001

A randomized trial of very early decompressive craniectomy in children with traumatic brain injury and sustained intracranial hypertension.  Taylor A, et al.
Child’s Nervous System 2001; 17: 154-162
Authors include Frank Shann & Jim Tibballs
RCT of early (19hrs median, 7-29hrs) decompressive craniectomy
Graph very illustrative of better ICP profiles
2/14 controls had good outcome (normal or mild disability) at 6 months
7/13 in decompression group
p=0.046, NS because of multiple peeks near end of study (required p of <0.02)
Therefore labelled a pilot study…

Summary

That’s all Folks!
Expect to hear from us again in 2 weeks, and as always, feel free to share your thoughts via the comments box below…

Back to the alphabet! D is for Disability, meaning: clinical assessment of neurologic function or dysfunction…

In this episode we talk about the assessment of neurologic status in the unwell or injured child, with particular reference to the Glasgow Coma Scale and its children, being various iterations of a Pediatric GCS. What is the validity and utility of these scales? Are they any more useful than “AVPU”?

D = Disability

Colin: introduction & disclaimer & welcome

Basics of assessing neurologic status:

Colin: “AVPU”

Alert
Verbal
Pain
Unresponsive

Simon: Pupils in the unconscious patient

Colin: causes of small pupils, causes of big pupils, unequal pupils = anisocoria

Simon: oculocephalic reflexes

Susan: GCS (generally) – usefulness in clinical practice – reproducibility, prognostic value for head injury vs other conditions

Colin: children’s GCS – any use at all?
One widely used version is from James 1986 [James HE. Neurologic evaluation and support in the child with an acute brain insult. Pediatric Ann. 1986; 15:16–22.]

(comments from group)

Colin: Differential diagnosis of coma / seizures / focal or non-focal neurology (DIMTOPPE mnemonic)

(comments from group, intussusception as a cause for altered conscious state)

DIMTOPPE

• D = drugs & toxins
  • extrinsic toxins
  • intrinsic toxins
    • liver failure
    • CCF
    • renal failure
    • respiratory failure
• I = infection
  • CNS
  • outside CNS
• M = metabolic & endocrine eg:
  • hypoglycaemia
  • hyponatraemia
  • hypo- or hyperthyroidism
• T = trauma
• O = oxygen deficiency
  • localised eg CVA (thrombotic or haemorrhagic)
  • global hypoxia (eg pneumonia)
• P = post-ictal state
• P = psychiatric / psychogenic
• E = oedema of the brain
  • Hypertensive encephalopathy
  • Space-Occupying Lesion

Nebulised Hypertonic Saline… Everybody’s talking about it. Well, they should be. Is this finally the treatment for bronchiolitis that we’ve been waiting for? Could a cheap, simple medication like this be the answer to massive health-care costs?

Bronchiolitis is such a common condition, that saving a day (or even half a day) of hospital length of stay across the board, would result in major savings to healthcare costs, across the world.
If this was a new or patented drug, we would have heard all about it!
In this episode we discuss 4 original papers related to Hypertonic Saline for bronchiolitis, as well as the reviews riding on these original works.

Nebulised Hypertonic Saline for Bronchiolitis: Outline of this PEMcast

CP: welcome, disclaimer, overview

CP: Sarrell 2002: Nebulized 3% hypertonic saline solution treatment in ambulatory children with viral bronchiolitis decreases symptoms. [Chest 2002; 122: 2015-20]

SF: Mandelberg 2003: Nebulized 3% hypertonic saline solution treatment in hospitalized infants with viral bronchiolitis. [Chest 2003; 123: 481-7]

KB: Tal 2006: Hypertonic saline / epinephrine treatment in hospitalized infants with viral bronchiolitis reduces hospitalization stay: 2 years experience. [Israeli Medical Association Journal 2006; 8: 169-73]

CP: Kuzik 2007: Nebulized hypertonic saline in the treatment of viral bronchiolitis in infants. [Journal of Pediatrics 2007; 151: 266-70]

SF: Zhang 2008 Cochrane review: Nebulized hypertonic saline solution for acute bronchiolitis in infants. [Cochrane Database of Systematic Reviews 2008; CD006458]

KB: Horner 2009 BestBET: Nebulised hypertonic saline significantly decreases length of hospital stay and reduces symptoms in children with bronchiolitis. [Emergency medicine Journal 2009; 26: 518-9]

CP: summary / opinions of others

All: conclusions, goodbye

Thanks for joining us… Post a comment! Are you using hypertonic saline nebs for bronchiolitis?

We interrupt the alphabet to bring you… respiratory viruses in the southern hemisphere. We wanted to get this one in before the end of bronchiolitis season.

Bronchiolitis is so common, we all need to know about it…

Overview of this PEMcast

Bronchiolitis basics, with reference to:

PMH Guideline (nod to Beccy Cresp)
Zorc & Hall 2010 review [Bronchiolitis: recent evidence on diagnosis and management. Pediatrics 2010; 125: 342-349 ]

CP: welcome, disclaimer, overview

What is bronchiolitis?

CP: Definition / epidemiology (northern WA less seasonal)
SF: Clinical features
KB: Natural History

Treatment for bronchiolitis:

CP: Steroids?
SF: Adrenaline?
KB: Beta agonists?
(asthma vs bronchiolitis in North American trials – age ‘cutoff’ )

Admission for Supportive Care :

CP: Oxygen
SF: Fluids (nod to CRIB study)
KB: other (natural history, high-risk groups, social)

Wrapping up:

CP: Tests
KB: Advice to parents
SF: Future directions

All: summary, goodbye, join us next time.

A Couple of Short Video Clips

This first clip demonstrates a prolonged expiratory phase and subcostal recession (right-click to toggle fullscreen view):

This clip was filmed in the dark… but the audio reveals the prolonged expiratory phase, and a bronchiolitic cough:

Thanks for joining us.  Feel free to share your insights as a comment…

IV Maintenance fluids for sick children: what fluid, and how much? This seemingly simple question has a controversial, complex and evolving answer.  Long-held traditions of giving hypotonic intravenous fluids to children have been increasingly challenged, due to dangerous adverse effects.

In this episode, we look at a few papers to address the hypotonic fluid controversy.
To listen, click on the play button below, or subscribe via iTunes.
As always, we welcome your comments, insights, or high-fives…

Overview

IV Maintenance fluids for sick children: what fluid, and how much?

(CP) 1957 Holliday & Segar: The maintenance need for water in parenteral fluid therapy. [Pediatrics 1957; 19: 823-832]

(SF) 2003 Moritz: Prevention of hospital-acquired hyponatraemia: a case for using isotonic saline. [Pediatrics 2003; 111: 227-30]

(KB) 2003 Duke: Intravenous fluids for seriously ill children: time to reconsider. [The Lancet 2003; 362: 1320-23]

(CP) 2004 Hoorn: Acute hyponatraemia related to intravenous fluid administration in hospitalised children: an observational study. [Pediatrics 2004; 113: 1279-84]

(MB) 2005 Holliday: Isotonic saline expands extracellular fluid and is inappropriate for maintenance therapy. [Pediatrics 2005; 115: 193-194]

(SF) 2007 Holliday: Fluid therapy for children: facts, fashions and questions. [Archives of Disease in Childhood 2007; 92: 546-550]

(KB) 2009 Yung: Randomised controlled trial of intravenous maintenance fluids. [Journal of Paediatrics and Child Health 2009; 45: 9-14]

(MB) 2010 Neville: Prevention of hyponatremia during maintenance intravenous fluid administration: a prospective randomised study of fluid type versus fluid rate. [The Journal of Pediatrics 2010; 156: 313-9]

Local/personal experience:

(CP) – JHC changed (several years ago) to N/Saline + 5% dextrose for under 5yrs, N/Saline over 5yrs
Manufactured ready-made [N/saline +5% DW] available, but only as 1 litre bags: use a burette!
Can make your own – safer to add sugar to N/Saline than adding Sodium to 5% dextrose
(remove 50mL from a 500mL bag of Normal Saline, add 50mL of 50% dextrose, ie 25g in 500mL = 5% dextrose)
Inertia, slow changes on wards but improving…

(MB) comments
(KB) comments
(SF) comments

Summary (CP)

That’s all folks! Thanks for playing. Send us a comment or an iTunes review, and we’ll speak to you soon…

Shock, dehydration, fluid management… How do we assess and manage the circulation in a paediatric emergency?
Learn about the clinical assessment of the Circulation in this PEMcast.

Click on the play button below to listen to this podcast, or subscribe using the iTunes button on the left…

Overview of Circulation (part 1) PEMcast

(CP) Introduction, disclaimer & welcome (gastro to be explored in separate episode)

Assessing circulation:

(KB) Elements: HR, CFT, pulses, BP, skin perfusion, mental status, urine output, general appearance (etc)
(SF) Shock: signs
(MB) Decreased BP late sign (why?)
(CP) ‘warm shock’ rare in kids
(KB) CFT caveats
(SF) Cutis marmorata can be normal or abnormal
(CP) Shock: causes (CHOD = cardiogenic, hypovolaemic, obstructive, distributive)
(KB) Shock: treatment: seek & treat cause; N/Saline boluses 20mL/kg; inotropes after 3rd bolus?
(SF) What inotrope? Adrenaline usually, Noradrenaline good for vasodilation in sepsis?

Dehydration – clinical signs & their evidence base:

See Steiner 2004 and Gorelick scale 1997
(CP) Fluid compartments & shifts (radio-labelled albumin experiments)
(KB) Various ‘scales’, unvalidated, no good evidence base
(MB) Local (PMH) study – inter-observer correlation
(SF) Steiner 2004: More features = more likely to be dry
Most predictive = CFT, respiratory pattern, skin turgor
Normal urine output reassuring, decreased urine output (by parental report) not predictive of dehydration
(All) Can we predict % dehydration clinically?
(KB) WHO recommendations now = none/some/severe

A 32 year old man presents with altered sensation and weakness in his right hand, the morning after an Iron Man event.
The event included several hours of cycling, using forearm rests. 
This short video clip demonstrates the typical ulnar claw hand posture and weakness of intrinsic hand muscles supplied by the ulnar nerve. 
If you look closely, you can see a touch of ‘cheating’ as in Froment’s sign: the thumb  is used to supplement the adduction of the fingers.  Flexor policis longus is supplied by the (intact) median nerve, whereas the palmar interossei are supplied by the ulnar nerve (remember PAD and DAB: Palmar ADduct and Dorsal ABduct).

What is the role for Non-Invasive Ventilation in the Paediatric Emergency Department?
Does NIV present the same rescue options as in adult respiratory emergencies, where blowing air through the window of opportunity can prevent endotracheal intubation?

In this PEMcast, we explore Bi-level Positive Airways Pressure and a few of its lesser-known cousins, using the limited literature as our map, and Dan as our tour-guide.

Random Useful Fact: 1mmHg = 13.6mmH2O = 1.36cmH2O

Outline of Audio Proceedings

CP: Role of NIV (“BiPAP”) in kids – reference to PEMP review

Noninvasive Ventilation Techniques in the Emergency Department: Applications in Pediatric Patients – by Jamie Deis & colleagues, Nashville TN, June 2009 (EBmedicine.net)

Theoretical advantages of NIV (WOB, metabolic demand of breathing, recruitment, FRC, gas exchange, V/Q mismatch, airway patency, hypoventilation)
Compared to ETT: less trauma, less sedation, more communication

Disadvantages (alertness/airway protection, shock/unstable, secretions/vomit/bleeding, co-operation, airway /upper GI surgery, staffing for coaching & monitoring)

Multiple modes of delivery, interfaces (masks facial/nasal, nasal prongs)

CPAP (5-10[15])

BiPAP (10-16[20]/5-10, start at 8-10/2-4; IPAP minus EPAP = PS)

HHFNC (humidified high-flow nasal cannula) 8L/min infants, 40L/min

Nasal IPPV (hi & lo CPAP cycles, not triggerable by patient) (start at 8&5)

KB: Thill 2004: Noninvasive positive-pressure ventilation in children with lower airway obstruction [Paediatric Critical Care Medicine 2004; 5: 337-342]
(crossover RCT, n=20)

CP: Beers 2007:  Bilevel positive airway pressure in the treatment of status asthmaticus in pediatrics [American J Emergency Medicine 2007; 25: 6-9]
(retrospective chart review, n=83)

We tried it. We liked it. Retrospective Chart review (methods some description, 1 reviewer, not blinded) No stats
BiPAP on billing → asthma

83 patients, median age 8 yrs, 2-17, IQR 5-11yrs
10 did not tolerate BiPAP (12%)

Of those who tolerated BiPAP (73):
77% improved RR (avg 24%drop), 88% improved SpO2 (avg 6.6 point rise)
22% escaped PICU admission (?effect of other treatments vs effect of BiPAP)

Only 2 patients subsequently intubated

Limitations:
“Failed routine treatment” – no clear indication for starting BiPAP
Additional interventions not controlled for (Mg, epinephrine, IV terbutaline)
No control group
No idea how many went straight to intubation & ventilation

“Safe & well-tolerated”, prospective studies needed

DA: Yanez 2008: A prospective, randomized, controlled trial of noninvasive ventilation in pediatric acute respiratory failure  [Paediatric Critical Care Medicine 2008; 9: 484-489]
(RCT, n=50)

All: SUMMARY / consensus