Tessa Davis. When should you worry about vital signs?, Don't Forget the Bubbles, 2014. Available at:
This week’s recommendation is a podcast by the wonderful SGEM.
Alfie, 6, is playing at local playground under Mum’s watchful eye. He goes down the slide and jumps off, landing on his hands and feet. He starts to cry and shows his Mum a syringe lying in the bark and a needlestick injury of his left hand. Mum is distraught when she brings Alfie into your department. What next?
- Needlestick injuries in the community are a source of great concern for parents.
- There is one reported case of seroconversion of Hepatitis B in children.
- The actual chance of viral transmission is very low.
- Ensure your patient is immunised!
- High risk patients should be discussed with your local infectious disease team for consideration of post-exposure prophylaxis.
- Educate children not to handles needles – 2/3 CANSI’s are from intentional handling!
There is a risk of transmission of Hepatitis B, Hepatits C or HIV from a community-acquired needlestick injury (CANSI). Although the risk is very low, this is a source of significant concern to parents. Several studies lasting from several months to nearly two decades in length have looked at the epidemiology of CANSIs. These studies, undertaken in Melbourne, Montreal, Birmingham and Perth broadly agree that;
~65% CANSIs occur in boys
Mean age is around 6-8 years
In two-thirds of CANSIs, the syringe or needle was intentionally handled by the child
The most common site of injury was the hand
About a quarter of wounds bled
In the Melbourne study CANSIs often occurred in public places in parks (30%), in the street (18%), in carparks (5%) and at the beach (6%). In Montreal, CANSIs occurred predominantly in the street (30%) and in parks (24%). Whilst the obvious difference is the lack of beaches in downtown Montreal, it’s also worth noting that a number of CANSIs must also occur in private residences.
Each of the papers described the baseline prevalence of HBV, HCV & HIV in their population, as well as the same prevalence within the IVDU community. None of the papers reviewed (total patients 416) reported any cases of seroconversion to Hep B, Hep C or HIV. There is a single case report of seroconversion to Hepatitis B after a CANSI in a child, reported in Barcelona in 1997. In 1999, Bowden et al, proposed conversion rates in the Victorian population to be around 6-30% for HepB, 0-7% for HepC and 0.4% HIV.
Although the risk is largely theoretical, factors that are considered to be high risk for acquired infection are:
These children should be discussed with your local infectious diseases team for consideration of HIV post-exposure prophylaxis, after their initial management.
Wash the wound with soap and water.
Ensure the syringe/needle has been safely disposed
History of note:
Take blood for HepB Surface antibody (HepB AbS) in a serum gel tube to store.
Consider tetanus vaccine +/- tetanus immunoglobulin.
Not required if immunised against tetanus in last five years.
If unimmunised, for immunoglobulin and vaccine.
Otherwise, if previously immunised, for booster dose.
Hepatitis B vaccination +/- Hep B immunoglobulin
If unimmunised, give first dose of vaccine and HepB Ig within 72 hours of exposure (in different limbs!)
If immunised, check titre & give booster.
Luckily, Alfie is immunised for both Hepatitis B and Tetanus. After a thorough wash of his hand, and some relatively obliging blood tests, he’s ready for home. His Mum asks if he needs any other medicine to reduce the risk of “catching one of those viruses you mentioned.”
There is a larger argument that there are risks associated with Hepatitis B immunoglobulin, including that of acquired infection, which must be weighted against the potential benefits of preventing a seroconversion when this may be highly unlikely in the first instance.
In the UK, Hep B immunoglobulin is only recommended in patients with exposure to known Hepatitis B source, although there is some leeway depending on the clinical circumstances. The Auckland District Health Board (ADHB), in NZ states “Administration of hepatitis immune globulin (HBIG) is not indicated if the child has completed a standard three-dose regimen of hepatitis B vaccination.” RCH Melbourne advises to offer HBIG to all unimmunised children with CANSI. There remains controversy in this component of management.
Hence, if the decision is made to treat, give HBIG within 72hrs.
(In Australia, Hep B Immunoglobulin is provided by the Red Cross Blood Service.)
Give the HBIG in a different limb to the Hep B booster you’ve just administered!
<30kg – give 100 iu IM injection
>30kg – give 400 iu IM injection
The papers reviewed had no reports of viral transmission of HIV from a CANSI. All mentioned antiretroviral therapy as potential post-exposure prophylaxis for HIV exposure. There were no clear guidelines on which children should be offered HIV-PEP; the ‘high-risk’ patients identified in the list above were more likely to receive prophylaxis. In the Montreal study, of the 210 patients who presented thereafter, an offer of prophylaxis to 87 patients (41.4%) was documented, and 82 (94.3%) of these patients accepted. Prophylaxis was zidovudine and lamivudine for 28 days in 74 patients (90.2%), additionally eight patients were also prescribed a protease inhibitor (nelfinavir, indinavir or ritonavir). Papenburg and colleagues go on to describe the rates of adverse effects from these medications. Consideration of HIV:PEP should be discussed with the local infectious diseases team.
Although the risk of seroconversion is low, it’s important not to underestimate the stress a needlestick will place on the child and family. Provide reassurance that the risk of viral transmission from a CANSI is very low. Don’t forget some written information about completing a catch-up course of immunisation. Contact your local paediatric infectious disease team; they may be happy to provide additional follow-up or counselling. That being said, always consider the prevalence of the blood-borne viruses where you work! The majority of DFTB readers are working in the Australasian, United Kingdom & North American settings; within and without these areas, the prevalence of Hep B, C & HIV can vary considerably.
It’s also worth noting that the studies mentioned probably underestimate the rate of CANSIs; not all children with a needlestick injury will tell their parents, and likewise, not all parents whose child reports a needlestick injury will present for care.
Finally, there’s clearly a huge public health component of this issue. Papenburg et al. identified that in nearly two-thirds of cases, the child actively handled the needle; it’s important to teach children to avoid any discarded syringes or needles and to tell an adult.
Russell FM. Nash MC. A prospective study of children with community-acquired needlestick injuries in Melbourne. Journal of Paediatrics & Child Health. 38(3):322-3, 2002 Jun. https://onlinelibrary.wiley.com/doi/10.1046/j.1440-1754.2002.t01-2-00859.x/abstract
Papenburg J. Blais D. Moore D. Al-Hosni M. Laferriere C. Tapiero B. Quach C. Pediatric injuries from needles discarded in the community: epidemiology and risk of seroconversion. Pediatrics. 122(2):e487-92, 2008 Aug. https://www.academia.edu/942640/Pediatric_injuries_from_needles_discarded_in_the_community_epidemiology_and_risk_of_seroconversion
Celenza, A. et al. Audit of emergency department assessment and management of patients presenting with community-acquired needle stick injuries. Australian Health Review, 2011, 35, 57–62. https://www.ncbi.nlm.nih.gov/pubmed/21367332
Garc ́ıa-Algar O, Vall O. Hepatitis B virus infection from a needle stick. Pediatr Infect Dis J. 1997;16(11):1099 https://journals.lww.com/pidj/Citation/1997/11000/Hepatitis_B_Virus_Infection_From_A_Needle_Stick.27.aspx
Makwana N. Riordan FA. Prospective study of community needlestick injuries. Archives of Disease in Childhood. 90(5):523-4, 2005 May. https://adc.bmj.com/content/90/5/523.short
Bowden S, Druce J, Kelly H. Stability of blood-borne viruses in the environment and risk of infection. Victorian Infect. Dis. Bull. 1999; 2: 71–2. https://docs.health.vic.gov.au/docs/doc/D785EE77B8899CD1CA2578C4000219EA/$FILE/vidbv2i4.pdf
Starship Children’s Hospital, Auckland, NZ – Clinical Guidelines (Needlestick Injuries) https://www.adhb.govt.nz/starshipclinicalguidelines/Needlestick%20Injuries.htm
Decle, P. Post-Exposure Prophylaxis (PEP) guidelines for children and adolescents exposed to blood-borne viruses 06/08/2011 https://www.chiva.org.uk/professionals/health/guidelines/pep/young-pep-ref.html
Royal Children’s Hospital, Melbourne, Clinical Practice Guidelines – Needlestick Injury https://www.rch.org.au/clinicalguide/guideline_index/Needle_Stick_Injury/
Updated 5/11/2017: Corrected initial investigations from HepB Surface
Antigen to Antibody. See comments below.
The mercury on the outside thermometer is inching past 40oC for the third day in a row and for once you are grateful to be in the cool, air-conditioned emergency department. The emergency phone snaps you back into alertness. The paramedics are bringing in a toddler that has been liberated from the back of a parked car.
During the recent heatwave in Melbourne, when the temperature topped 40 degrees for four days straight, Ambulance Victoria received 60 calls for children trapped in cars. Fortunately, there were no fatalities. During the 1995-2002 period in the United States, there were 171 entirely preventable deaths.
Studies have suggested that on a hot day the temperature in a locked vehicle can rise as high as 51-67oC within 15 minutes. 75% of this rise occurs within the first five minutes of the door closing, so even short periods of leaving a child unattended can be dangerous. There is some evidence that leaving the window cracked can make a difference but all the data suggests that it has to be open at least 20 cm to make an appreciable difference.
Even though kids have a larger body surface area-to-mass ratio than adults, they have much less effective thermoregulation. They have a higher metabolic rate so are really little furnaces. Unfortunately, they are less well able to regulate their cardiac output in response to heat stress and produce less sweat per apocrine gland compared to adults. Perhaps more importantly, unlike most adults, they cannot get out if they are left in the car seat on their own.
Words are important. What the lay public means when they say heatstroke is very different from what the medical professional means.
Heat stress is what we all feel when the mercury rises – we’re grumpy, irritable, sweaty and often listless but not unwell. The core temperature is unaffected.
Heat exhaustion occurs as a result of salt and/or water depletion.It may be compounded by nausea, vomiting and excessive sweating. The core temperature may or may not be up altered.
Heatstroke is a medical emergency and typically classified as either exertional (think running a marathon on a hot day) or non-exertional (sitting in a hot car). As the core temperature rises above 40oC the patient often becomes more lethargic and delirious. Seizures, then coma, eventually ensue.
Heat is lost via radiation, conduction, evaporation, and convection with these latter two being most amenable to change.
As with all potentially toxic exposures (to heat in this instance) removal from the source is vital. The child should be managed in a cool environment if possible and attention paid to their ABCs.
There is no evidence that antipyretics lower the temperature in cases of heat-related illness.
Disposition for the sick patient is straight forward. They need admission to HDU/ICU. But what should you do for the well-appearing child?
There is no consensus as to how long a patient should be observed but common sense would dictate that if their temperature has normalized and they are rehydrated then they are fit enough to go home.
That is the million-dollar question. Certainly, in Australia, Section 231 of the Children and Young Persons (Care and Protection) Act 1998 clearly states:-
A person who leaves any child or young person in the person’s care in a motor vehicle without proper supervision for such a period or in such circumstances that :
(a) the child or young person becomes or is likely to become emotionally distressed, or
(b) the child’s or young persons health becomes or is likely to become permanently or temporarily impaired is guilty of an offence.
Hasn’t the distraught parent been through enough? This excellent piece from the Washington Post, entitled Fatal Distraction eloquently puts parents struggle into words.
Little Nelly is brought in, nearly naked and crying. Her rectal temperature is 38oC and she tolerates a delicious icy pole. Her mother is beside herself. You discuss the case with the local social services who agree to follow up.
McLaren C, Null J, Quinn J. Heat stress from enclosed vehicles: moderate ambient temperatures cause significant temperature rise in enclosed vehicles. Pediatrics. 2005 Jul;116(1):e109-12. PubMed PMID: 15995010
King K, Negus K, Vance JC. Heat stress in motor vehicles: a problem in infancy. Pediatrics. 1981 Oct;68(4):579-82. PubMed PMID: 7322691.
Grubenhoff, Joseph A., Kelley du Ford, and Genie E. Roosevelt. “Heat-related illness.” Clinical Pediatric Emergency Medicine 8.1 (2007): 59-64.
Guard, A., and Susan Scavo Gallagher. “Heat related deaths to young children in parked cars: an analysis of 171 fatalities in the United States, 1995–2002.”Injury Prevention 11.1 (2005): 33-37.
https://lifeinthefastlane.com/education/ccc/heat-stroke/ accessed 21st January 2014
Bouchama, Abderrezak, and James P. Knochel. “Heat stroke.” New England Journal of Medicine 346.25 (2002): 1978-1988.
This week’s recommendation is from the team at the Intensive Care Network – The Intensive Care Podcasts.
It’s Fran Lockie (a Paediatrician in Adelaide) discussing how to manage little adults in resus situations.
Kids come into emergency EVERY day with head injury. In many cases imaging decisions are simple. Especially when the child rolled off the bed, cried straight away & is now tearing up the ED – BUT plenty of cases present a diagnostic dilemma for physicians.
Unless your skills are tip top, the chances are that you will have had a traumatic tap before (studies suggest up to 40% of lumbar punctures). Blood in the CSF on lumbar puncture can be a sign of a subarachnoid haemorrhage but more commonly is due to a traumatic tap (if the number of red cells in consecutive samples remains the same, it’s likely to be an SAH, but if they reduce then it’s likely due to a traumatic tap).
4 year old Dudley is brought into your emergency department by his hysterical mother. In between breathless sobs she tells you how she accidentally slammed the car door shut on his hand. She is convinced he has lost a finger given how much he is screaming.
The batphone rings at 5am. You are given a 5 minute ‘heads up’ by paramedics regarding a 3 year old child they are rushing to you with lights & sirens. She has a history of seizure disorder and has been actively seizing for 45 minutes….
We often see children with pyrexia and have to decide on whether or not they have a serious underlying bacterial infection. When the parent describes, or uses the word ‘rigors’ we all get a bit twitchy ourselves. But is there any evidence to suggest that rigors = serious bacterial infection?