Making the Call in NAI: Bindu Bali at DFTB18

Cite this article as:
Team DFTB. Making the Call in NAI: Bindu Bali at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17854

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Non-Accidental Long Bone Injuries: Nikki Abela at DFTB18

Cite this article as:
Team DFTB. Non-Accidental Long Bone Injuries: Nikki Abela at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17833

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Cognitive Biases: Kevin McCaffrey at DFTB18

Cite this article as:
Team DFTB. Cognitive Biases: Kevin McCaffrey at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17768

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

Delayed presentation of head injuries – should we be worried?

Cite this article as:
Tessa Davis. Delayed presentation of head injuries – should we be worried?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17874

We have a clear algorithm for when to CT children who present with head injuries immediately after the injury. But, when children present more than 24 hours after an injury, we aren’t really sure what is best practice. This paper, by the PREDICT group, look at the rates of traumatic brain injury in this patient group.

Borland M,  Dalziel SR, Phillips N, Lyttle M, Bressan S, Oakley E, Hearps SJC, Kochar A, Furyk J, Cheek J, Neutze J, Gilhotra Y, Dalton S, Babl F. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study, Annals of Emergency Medicine, DOI: https://doi.org/10.1016/j.annemergmed.2018.11.035

Why is this study needed?

We have a range of decision rules to help guide us for children presenting immediately after a head injury. PECARN and CATCH clinical decision rules specifically exclude children who present with a head injury more than 24 hours after the injury. CHALICE doesn’t specifically exclude this group, but there is no published data on this group of patients.

What we worry about is missing a traumatic brain injury, and in particular one that will need surgical intervention. If a child presents after the initial 24 hours, are they more likely to have a traumatic brain injury and should we therefore have a lower threshold to CT scan these patients?

This is a really common dilemma in Paediatric Emergency, and in my own experience, most people have a lower threshold for scanning children presenting late with head injury concerns because of the lack of guidance and evidence in this group.

The authors’ aim is to look at the prevalence of traumatic brain injury in this group, and to identify any factors in these patients that would make a traumatic brain injury more likely.

Who were the patients?

This was a secondary analysis of an existing cohort – the Australian Paediatric Head Injury Study cohort. This was children with a head injury who presented to one of ten paediatric EDs in Australia/New Zealand over a 3.5 year period.

For this secondary analysis, the cohort was split into those presenting within 24 hours, and those presenting later than 24 hours after the head injury. 5% of the cohort presented >24 hours after the injury.

Children were excluded if they had GCS<14, and were also excluded for representations of the same injury.

The original APHIRST cohort included 20,137 head injury presentations.

352 were excluded due to GSC<14 and 20 were excluded due to unknown time to presentation.

Of the 19,765 left, 981 children presented >24 hours after the injury.

Definitions

Traumatic brain injury on CT (TBI) – intracranial haemorrhage or contusion, cerebral oedema, traumatic infarction, diffuse axonal injury, shearing injury, sigmoid sinus thrombosis, signs of brain herniation, midline shift, diastasis of the skull, pneumocephalus, and depressed skull fracture.

Clinically important traumatic brain injury (cTBI) – death, intubation >24 hours, neurosurgery, or a traumatic brain injury-related admission to hospital of two or more nights.

What were the authors looking at?

The paper examined any associations between a delay in presentation and the mechanism of injury.

It also looked at the injury characteristics and demographics for patients presenting within and after 24 hours of the injury.

Who presented more than 24 hours after a head injury?

Those presenting >24 hours after the injury were significantly more likely to have had a non-frontal scalp haematoma, headache, vomiting, and assault with non-accidental injury concerns.

Loss of consciousness and amnesia were more likely to present within 24 hours of the injury.

Were the late presentations more likely to have a head CT and a brain injury than those presenting within 24 hours?

203 of the 981 patients had a head CT in the late group. This is 20.6% compared to 7.9% in the early presentations.

37 of these children had a TBI on head CT. This is 3.8% compared to 1.2% in the early presentations group. The most common injuries were a depressed skull fracture, intracranial haemorrhage, or contusions.

Eight children had a cTBI (0.8% – which is the same as in the early group) and two required neurosurgical intervention (also not significantly higher than in the early group).

Who were the eight children with clinically important traumatic brain injuries?

The children ranged from six months to 15 years.

  • Five of them had a low-level fall (<1 m) – one of these required neurosurgical intervention
  • One was struck by a high speed object
  • One sustained a blunt injury with a bat during sport – required neurosurgical intervention
  • One fell out of bed more than two days earlier

Of note in the late group…

No children with amnesia had a traumatic brain injury on head CT

Suspicion of a depressed skull fracture and a non-frontal scalp haematoma were significantly associated with a cTBI

No children with loss of consciousness had a cTBI

What can we take from this?

There may be many reasons why our scanning rate in delayed head injury presentations is so much higher – including the lack of previously existing evidence, and our clinical concern that a TBI is more likely if the symptoms are persisting.

The authors conclude that presenting >24 hours after the injury (with a GSC>14), significantly increases the risk of a TBI. Suspicion of depressed skull fracture or a non-frontal scalp haematoma increase the risk of TBI and cTBI in this group.

Commentary from Damian Roland:

This is a useful sub-analysis of a very good research data set prepared by the PREDICT group which has good face validity and is likely to be externally reproducible in other developed nations.

The question I ask myself when reviewing head injury patients with a ‘delayed’ presentation is ‘why are you delayed?’. The sheer size of this data set is testament to the fact that lots of children present to Emergency Departments because of parental concern following a fall or blunt trauma. If a parent chooses not to present initially it’s usually because they thought the injury was not that significant (not a very high bar to reach usually!) and symptoms have evolved or perhaps the initial circumstances weren’t clear or un-witnessed. For the former case this ‘evolution’ of disease is (not surprisingly) significant. The ‘delayed’ group more likely to demonstrate relevant pathology because the symptoms that pathology were producing were becoming more apparent. For the latter “historical’ muddying is either sinister (note the relationship with non-accidental injury concerns) or perhaps critical information which may have resulted in earlier attendance has been missed.

It is important to note that while the post 24 hour group demonstrated increased risks for many features and outcomes, the absolute numbers are still low. Just because you present 24 hours down the line doesn’t mean do a CT. Just think that bit more carefully than if the child had presented straight after the injury. As this same group have also recently shown, our individual decision making capacity is probably just as good as any rule so we can still trust our own clinical judgement

.

Steroids in Wheeze: Meredith Borland at DFTB18

Cite this article as:
Team DFTB. Steroids in Wheeze: Meredith Borland at DFTB18, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17716

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story’ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families. Tickets for DFTB19, which will be held in London, UK, are now on sale from www.dftb19.com.

ADC/DFTB Journal Club #2 – December – How well do we manage suspected meningitis in ED?

Cite this article as:
Grace Leo. ADC/DFTB Journal Club #2 – December – How well do we manage suspected meningitis in ED?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17786

Vaccines have been instrumental in reducing rates of bacterial meningitis. However bacterial meningitis still represents 4-19% (1) of cases of meningitis and has been estimated to be cause 2% of all child deaths (2). Timely administration of antibiotics helps save lives with adult research suggesting that every hour of delayed treatment increases the risk of death or permanent disability by 10-30% (3). So how swiftly do we investigate and treat children with suspected meningitis? The paper from Archives of Disease of Childhood featured in our second #DFTB_JC sought to answer this question:

 

What’s it about?

This was a prospective cohort study of 388 children who attended three UK paediatric tertiary centres between 2011-2. They had been either hospitalised with suspected meningitis or underwent lumbar puncture (LP) during sepsis evaluation.

Of the 388 children, 18% (70) were given a diagnosis of meningitis but only 13 were documented as bacterial and 26 as viral with and 31 patients having no known or identified cause. Just over half the children (57%) had seen a doctor in the same illness prior to ED presentation.

The median time from initial hospital assessment to antibiotic administration was 3.1 hours.  The time to LP was even longer at 4.8 hours, but once discounting intentional postponement for reasons including convulsions, concern regarding raised intracranial pressure, coagulopathy or shock, this time reduced to 3 hours. Over half of the children (62%) had their LP following antibiotics.

In further discussion with the corresponding author @manishs_  the mean was chosen due to skewing of the data and the time from initial hospital assessment was equivalent to arrival in ED. The time between initial assessment and LP ranged from 0-183 hours whilst the time between initial assessment and antibiotics ranged from 0 to 136 hours. For the 221 patients who they had data in hours available; only 31 received antibiotics in the first hour. However 131 of the 221 patients did receive antibiotics in the first 4 hours.

 

 

The general sentiment from the twitter discussion was  that the median time of 3.1hours to antibiotic administration was longer than expected, and suboptimal. Whilst the actual time point may have been somewhat surprising; many could identify common reasons for antibiotic delay and in particular, discussion about the difficulties that lumbar puncture can pose in different age groups and its contribution towards delay of antibiotics.

“It surprised me. Think we generally give abx before LP in children and LP before abx in babies… probably because of less anxiety around the procedure in babies. But no excuse for 3 hour delay in any age group really.” – @DrRoseM

 

 

 

We then delved deeper into the importance of LP before or after antibiotics and factors affecting unintentional LP delay. Paediatrician from Ontario, Tom Lacroix shared concern that with improved vaccines, he has seen skill attrition.

“…I wonder how much of delay is bc we have become unaccustomed to doing LPs. I have seen a fall in LPs 90%+ since intro of pneumococcal conjugate vaccine” – @drtom_lacroix

Across in the UK, the perceived anxiety surrounding performing an LP in older children was raised including staffing challenges, concerns about pain and procedural sedation.

“In neonates we rush to get the LP done within an hour, but in older children it always seems to take a lot longer. Do we have misplaced anxiety in this age group?” – @TessaRDavis

“…It takes one NICU nurse to flex a 6 day old up for an LP, but a play specialist, at least two nurses and one parent to get an older child in position for an LP” – @edd_broad

Differences in practice in terms of performing a FBC and Coags screen prior to LP were also highlighted.

“Not sure about mandatory, but I’ve been taught (and continue to practice) confirming PLT > 50×10^9/L prior to LP. ” – @henrygoldstein

“…Unless evidence of coagulopathy ie purpura. Do LP and then give abx” – @DocAnthonyT

 

 

 

In the supplementary tables from the paper, of all children in the study, just under a quarter (24.7%) had bacterial and/or viral CSF PCR performed. Of the 70 children who had meningitis, CSF PCR was performed on only 9 (13%). The rate was slightly higher for meningitis of cause unknown (6 of 29 patients, 21%). The authors commented that this represents a significant underutilisation, particularly as CSF PCR is recommended in the current UK guidelines. The suspected cause of this was a long turnaround time to PCR.

However the benefits of positive viral CSF PCR results would include reducing length of treatment and inpatient stay as well as building a more accurate understanding of true disease rates.

The results of this paper contrast with experiences of our journal club participants where CSF PCR appeared to be a more common order, particularly in the neonatal setting:

“Might depend on the CSF WCC for the bacterial PCR? If zero, I wouldn’t necessarily send bacterial PCR (but will still frequently send viral PCR)…Parechovirus PCR is automatically sent for our neonates. #DFTB_JC ” – @DrSarahMcNab

“NICU where I work send viral PCRs as standard with turnaround in 24 hours. Think you still need to request in paeds. ” – @DavidKing83

 

Paediatric Registrar Rose provided a good summary of what she learned from the article and the #DFTB_JC chat:

take home- give the abx as soon as possible and definitely within 1 hour. If unable to do LP pre abx due to delays etc then do LP ASAP after abx. Consider PCR as a valuable tool to aid decision re duration of treatment” – @DrRoseM

From the DFTB team, the discussion has made us rethink how each step in assessment and management of suspected meningitis may delay optimal care. In particular we’ll be thinking about how strong the evidence is behind ‘the golden hour’ of antibiotic administration, the anxiety surrounding LPs in older children and evidence behind performing coagulation studies prior to LP…now that sounds like a potential post for the future.

Thanks again to everyone who participated in our #DFTB_JC and we hope you will join us again later this month for our next paper.

 

Please join us for our next ADC/DFTB Journal Club on twitter at Tue 22/1/19 at UTC2000hrs (That’s Wednesday 0700 23/1 AEST) January’s featured FREE access article from @ADC_BMJ featuring a FREE access article from the latest issues of Archives of Disease of Childhood. January’s pick  is ‘ Can we use POCUS to Diagnose Pneumonia?’ Read the article here: bit.ly/2TMDf2M The chat will happen on twitter, hosted by @DFTB_Bubbles. Remember to use the hashtag #DFTB_JC for all related posts.

Thoracolumbar spine x-rays

Cite this article as:
Tessa Davis. Thoracolumbar spine x-rays, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17581

Read our step-by-step guide to interpreting thoracic and lumbar spine x-rays.

Thoracolumbar spine x-ray involves two views – AP and lateral.

 

  1. Check it’s an adequate view

For a lumbar spine view

  • you should be able to see L1-L5 but also the full T12 vertebral body, T11/12, and the sacrum on the AP view
  • the vertebral bodies, facet joints, and pedicles should be clearly visible on the lateral view
  • the transverse processes should also be visible (and are often obscured by gas)

For the thoracic spine view

  • make sure the whole thoracic spine is visible
  • you should be able to see the pedicles, spinous processes, and vertebral bodies
  • the ribs can cause difficulty seeing the thoracic spine on a lateral view

 

2. Know your anatomy

  • Clavicle is at T3
  • Tracheal bifurcation is T4/5
  • 12th rib is at T12
  • In the lumbar spine, the disc spaces also increase in size, although note that the L5/sacral space is narrower than the L4/L5 space

From https://www.wikiradiography.net/

3. Check the alignment

On the AP check that the vertebral bodies and spinous processes are aligned. On the lateral, check the alignment of the vertebral bodies.

 

 

4. Look for loss of vertebral height

In the thoracic spine, the vertebral bodies (and the disc spaces) should gradually increase in size as you get further down the spine.

Check all the vertebral bodies looking specifically for loss of height. This indicates a compression fracture.

 

 

 

5. Look for widened inter-spinous or inter-pedicle distance and check the processes

In the lumbar spine check that all the pedicles, spinal, and transverse processes are intact.

See below (under burst fracture) for an example of widened inter-pedicle distance and (under Chance fracture) widened spinous process process distance.

Transverse process fracture From https://www.imageinterpretation.co.uk/thoracolumbar.php

 

6. Check for translation/rotation or distraction

Translation or rotation is displacement in horizontal plane; and distraction is displacement in the vertical plane.

Translation/rotation is due to a side-to-side motion (can be left-to-right or front-to-back). It is a serious injury and always involves the posterior ligamentous complex.

Distraction is where the vertebrae are pulled apart and carries a high risk of cord injury. Often there is compression at the other side (see Chance fracture below).

 

7. Know the common types of fractures

Compression fracture

This is the most common type of fracture and is identified through loss of vertebral height (see number 4 above). It involves one column only and is a stable fracture.

 

Burst fracture

On x-ray alone 25% of burst fractures are misdiagnosed as vertebral compression fractures. A burst fracture is where there is a compression, but part of the vertebral body has been projected out anteriorly.

On AP view there will be an increased interpedicular distance in 80% of burst fractures.

On lateral view there will be reduced vertebral height and disrupted anterior alignment.

A burst fracture involves two columns and is usually considered to be unstable.

 

Chance fracture

Usually from a seatbelts injury and is commonly at L2/L3

This is a flexion-distraction injury where there is horizontal splitting of the vertebral body with ligament rupture. This is an unstable fracture and involves all three columns

Sometimes there is increased distance between the spinous processed on the lateral view (but not always).

On the AP view there can be increased distance between the spinous processes at the level of the Chance fracture.

 

Jumper’s/lover’s fracture

So-called because it’s usually from people jumping out of windows to escape the police or angry partners. This is severe axial loading leading to compression/burst fractures alongside a calcaneus fracture.

https://radiopaedia.org/articles/lovers-fracture-2?lang=us

References

Radiopaedia

Radiology Assistant

Norwich Image Interpretation Course

Radiology Masterclass

Thinking FAST, and slow

Cite this article as:
Andrew Tagg. Thinking FAST, and slow, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17324

10-year-old Elliott is brought into your emergency department after falling off his bike. Whilst trying to escape from a gang of bullies he went off-road, left the ground and landed awkwardly. The front wheel twisted and the handlebars hit his belly. He is complaining of pain in the left upper quadrant. He has been treated with intranasal fentanyl and is haemodynamically stable. Your registrar asks if he can do a FAST exam on him.

 

Basics principles of the FAST exam

The Focused Abdominal Sonography for Trauma exam superseded diagnostic peritoneal lavage in the late 1980s as a means of determining significant intra-abdominal free fluid. The actual monicker, FAST, was first used by Royzycki et al back in the mid-90s.

The FAST exam is a rapidly performed test that looks at four specific areas – RIGHT upper quadrant, LEFT upper quadrant, subxiphoid region, and pelvis. The wielder of the probe is looking for free fluid rather than directly looking for solid organ injury.

The 4 traditional FAST views – RUQ, LUQ, subxiphoid and pelvic.

It’s important to remember that the FAST exam came about as a tool to examine haemodynamically UNSTABLE patients in order to determine who needed to go to the operating theatre or needed a critical intervention (such as pericardiocentesis).

According to Rippey and Royce, the sensitivity of FAST in adults ranges from 64-98%. But…

 

What about in kids?

CT is considered the gold standard for the examination of intra-abdominal injury in children but it is not without risk. As clinicians we are reluctant to expose kids to needless radiation and try and act within the ALARA (As Low As Reasonably Possible) principle. With an increased focus on the use of point of care ultrasound throughout paediatrics it can be tempting to translate the adult approach of using the FAST scan, in kids.

A couple of concerns have been raised regarding the use of FAST in children:

 

Not all children with abdominal injuries have free fluid

A number of studies in haemodynamically stable children have found significant solid organ injuries (liver, spleen or kidney lacerations) on CT with normal bedside ultrasound. Whilst 22% of abdominal injuries in adults are not associated with free fluid this rises to a whopping 37% in children.

A 2007 meta-analysis by Holmes et al found an 80% sensitivity for detecting intra-peritoneal fluid via sonography. When the authors only looked at the more methodologically rigorous studies the sensitivity dropped to 66%.

 

The management of solid organ injuries in the paediatric population is different

Nearly all intra-abdominal injuries in children are managed conservatively and so accurate delineation is important. Finding free fluid on sonographic assessment does not mandate them going to theatre, even in the setting of haemodynamic instability. Operative management of hepatic injuries in children has been associated with higher mortality than a conservative approach.

 

So what does this all mean?

CT scanning does have its drawbacks – it involves ionising radiation, IV contrast and is time and money intensive in comparison with the FAST scan. But if ultrasound cannot tell us what we need to know then there is no comparison. A number of studies that have shown a better correlation between CT and US do not use the FAST scan but a modified form or even complete abdominal sonography by qualified sonographers. Given that US is very much an operator-dependent imaging modality it is vital that anyone using it has been trained (and accredited) in its use.

Emergency physicians may think they are amazing at performing a focused abdominal assessment and wield the probe at every given opportunity ‘for practice’. This will skew the accuracy of the test. If the pre-test probability of a positive result is low in the first place then the number of true negatives will, of course, be higher and the accuracy of the test will appear to be higher than it actually is.

In my attempt to trawl through some of the data I have consistently come across the idea that FAST is great because it is so accurate. The only way of knowing this is to look at the studies that compare it with a CT. Just because you do not pick up an injury immediately does not mean that one is not there. For example, in the Soudack et al. paper they described three negative FAST, positive CT cases – a haemo-peritoneum, one splenic laceration, and one hepatic laceration. Because the CT did not show free fluid these did not count as false-negatives!

A positive FAST is helpful but a negative one…not so much.

 

What do I do?

What I am really interested in is the Negative Predictive Value of the test i.e. the chance that if my scan is NEGATIVE there is NO free fluid. Unfortunately, a negative scan, in isolation does not tell me that there is not a significant intra-abdominal injury. In the setting of a worrying mechanism (e.g. handlebar versus spleen) with bruising and tenderness to the left upper quadrant and a NEGATIVE fast I cannot say that the child is okay and send them home. This is the concern that I have. That the test will stop the less astute clinician from thinking.

One has to be very wary when interpreting the literature surrounding FAST scans in paediatrics. All the scan tells you is that there is no free fluid. If the patient is haemodynamically stable and there is suspicion of an intra-abdominal injury then the patient should have a CT.

Haemodynamically stable patients

In the haemodynamically stable patient with an unconcerning physical exam, good quality images on a comprehensive abdominal ultrasound and the ability to serially examine the patient then a CT may not be warranted. A comprehensive abdominal ultrasound is NOT the same as FAST.

One might think that the use of ultrasound might have other benefits but a large study by Holmes et al. in 2017 showed no alteration in the number of CT scans requested, number of patients hospitalized or requiring surgery.

 

Haemodynamically unstable patients

These patients need resuscitation, often with blood products, until they are stable enough to enter the CT scanner/IR suite. A FAST scan is likely to be positive but given that over 90% of intra-abdominal injuries in children are managed without going to theatre it is unlikely to change my management.

Whilst this is clearly not a comprehensive review, any collection of data that has such a wide range of specificity needs to be considered. I could add another 10 studies and they might tighten up my spread but in the largest trials, involving ED physicians we are just not that great.

So the bottom line, when taken in isolation, as I see it is this best case/worst case…

Thanks to Arun Ilancheran and Ross Fisher for pushing me down this rabbit hole.

 

Selected references

Ashrafi A, Heydari F, Kolahdouzan M. The Utility of Ultrasound and Laboratory Data for Predicting Intra-abdominal Injury among Children with Blunt Abdominal Trauma. International Journal of Pediatrics. 2018 Aug 1;6(8):8047-59.

Calder BW, Vogel AM, Zhang J, Mauldin PD, Huang EY, Savoie KB, Santore MT, Tsao K, Ostovar-Kermani TG, Falcone RA, Dassinger MS. Focused assessment with sonography for trauma in children after blunt abdominal trauma: A multi-institutional analysis. Journal of Trauma and Acute Care Surgery. 2017 Aug 1;83(2):218-24.

Coley BD, Mutabagani KH, Martin LC, Zumberge N, Cooney DR, Caniano DA, Besner GE, Groner JI, Shiels WE. Focused abdominal sonography for trauma (FAST) in children with blunt abdominal trauma. Journal of Trauma and Acute Care Surgery. 2000 May 1;48(5):902-6.

Emery KH, McAneney CM, Racadio JM, Johnson ND, Evora DK, Garcia VF. Absent peritoneal fluid on screening trauma ultrasonography in children: a prospective comparison with computed tomography. Journal of pediatric surgery. 2001 Apr 1;36(4):565-9.

Fox JC, Boysen M, Gharahbaghian L, et al. Test characteristics of focused assessment of sonography for trauma for clinically significant abdominal free fluid in pediatric blunt abdominal trauma. Acad Emerg Med 2011; 18:477– 482.

Holmes JF, Brant WE, Bond WF, Sokolove PE, Kuppermann N. Emergency department ultrasonography in the evaluation of hypotensive and normotensive children with blunt abdominal trauma. Journal of pediatric surgery. 2001 Jul 1;36(7):968-73.

Holmes JF, Kelley KM, Wootton-Gorges SL, Utter GH, Abramson LP, Rose JS, Tancredi DJ, Kuppermann N. Effect of abdominal ultrasound on clinical care, outcomes, and resource use among children with blunt torso trauma: a randomized clinical trial. Jama. 2017 Jun 13;317(22):2290-6.

Holmes JF, Gladman A, Chang CH. Performance of abdominal ultrasonography in pediatric blunt trauma patients: a meta-analysis. Journal of pediatric surgery. 2007 Sep 1;42(9):1588-94.

Kessler DO. Abdominal Ultrasound for Pediatric Blunt Trauma: FAST Is Not Always Better. Jama. 2017 Jun 13;317(22):2283-5.

Menaker J, Blumberg S, Wisner DH, Dayan PS, Tunik M, Garcia M, Mahajan P, Page K, Monroe D, Borgialli D, Kuppermann N. Use of the focused assessment with sonography for trauma (FAST) examination and its impact on abdominal computed tomography use in hemodynamically stable children with blunt torso trauma. Journal of Trauma and Acute Care Surgery. 2014 Sep 1;77(3):427-32.

Moore C, Liu R. Not so FAST—let’s not abandon the pediatric focused assessment with sonography in trauma yet. Journal of thoracic disease. 2018 Jan;10(1):1.

Murphy R, Ghosh A. The accuracy of abdominal ultrasound in paediatric trauma. Emergency medicine journal: EMJ. 2001 May;18(3):208.

Mutabagani KH, Coley BD, Zumberge N, McCarthy DW, Besner GE, Caniano DA, Cooney DR. Preliminary experience with focused abdominal sonography for trauma (FAST) in children: is it useful?. Journal of pediatric surgery. 1999 Jan 1;34(1):48-54.

Retzlaff T, Hirsch W, Till H, Rolle U. Is sonography reliable for the diagnosis of pediatric blunt abdominal trauma?. Journal of pediatric surgery. 2010 May 1;45(5):912-5.

Rippey JC, Royse AG. Ultrasound in trauma. Best Practice & Research Clinical Anaesthesiology. 2009 Sep 1;23(3):343-62.

Rozycki GS, Ochsner MG, Jaffin JH & Champion HR. Prospective evaluation of surgeons’ use of ultrasound in the evaluation of trauma patients. The Journal of Trauma 1993 Apr; 34(4): 516–526. discussion 26–7.

Scaife ER, Rollins MD, Barnhart DC, Downey EC, Black RE, Meyers RL, Stevens MH, Gordon S, Prince JS, Battaglia D, Fenton SJ. The role of focused abdominal sonography for trauma (FAST) in pediatric trauma evaluation. Journal of pediatric surgery. 2013 Jun 1;48(6):1377-83.

Schonfeld D, Lee LK. Blunt abdominal trauma in children. Current opinion in pediatrics. 2012 Jun 1;24(3):314-8.

Soudack M, Epelman M, Maor R, Hayari L, Shoshani G, Heyman‐Reiss A, Michaelson M, Gaitini D. Experience with focused abdominal sonography for trauma (FAST) in 313 pediatric patients. Journal of Clinical Ultrasound. 2004 Feb;32(2):53-61.

Soundappan SV, Holland AJ, Cass DT, Lam A. Diagnostic accuracy of surgeon-performed focused abdominal sonography (FAST) in blunt paediatric trauma. Injury. 2005 Aug 1;36(8):970-5.

Suthers SE, Albrecht R, Foley D, Mantor PC. Surgeon-Directed Ultrasound for Trauma is a Predictor of Intra-Abdominal Injury in Children/DISCUSSION. The American surgeon. 2004 Feb 1;70(2):164.

Stabbings in adolescents

Cite this article as:
Tessa Davis. Stabbings in adolescents, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17337

It’s a regular day in your Paeds ED. You’ve just pulled a piece of lego out of a child left nostril; there are two wheezy kids waiting for review to see if they can stretch to two hours; and there is a 2 month old with a rash that you’re currently seeing  – everyone is waiting for you to come up with a clever diagnosis. As you stare at the spots and wait for some inspiration, you hear one of your nursing colleagues call…

Neonatal jaundice – the basics

Cite this article as:
Shalome Kanagaratnam. Neonatal jaundice – the basics, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17047

Most newborns are jaundiced. Indeed, 60% of term infants, 80% of premies and 33% of breastfed babies are jaundiced in early life. Fortunately, the majority of these self-resolve and have no sinister underlying cause. But how do we identify those who require urgent management? How can we effectively and confidently reassure anxious patients whilst ensuring we don’t miss a significant diagnosis?

How to draw a Genogram

Cite this article as:
Daniel Bakhsh. How to draw a Genogram, Don't Forget the Bubbles, 2018. Available at:
https://doi.org/10.31440/DFTB.17132

As a Student Doctor at the University of Queensland, I was offered the opportunity to shadow the Adolescent Team at The Child and Youth Mental Health Service (or CYMHS) at the Queensland Children’s Hospital. This was an amazing opportunity to observe some really important work in two of my special interest areas: Paediatrics and Psychiatry. The attachment really drove home that patients don’t exist in isolation, and how this is particularly true for children. The surrounding family system strongly dictates how well they will fare once they leave the hospital.

As part of this attachment I was asked to prepare and present Genograms for every patient at the weekly Multidisciplinary Team meeting. As I began to interview family members in order to gather the required 3 generations of family history, it became clear to me that a small diagram could represent and quickly convey what would otherwise have taken several pages of text. Genograms provide a wealth of insight at a glance, can help align patients with their most appropriate care, and are relatively easy to draw once you know how. They are a mainstay of Paediatrics for a reason.

When I first came across Genograms as a student, attempting to create one was very confusing and a little overwhelming. There are also surprisingly few reference materials available to aid you along the way. So in order to make this task a little easier for the next student, I put together this little video. I hope you find it useful.

– Daniel Bakhsh, Student Doctor, Doctor of Medicine Program, University of Queensland