Problems with ear piercing

Cite this article as:
Andrew Tagg. Problems with ear piercing, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3374

Krystal is seven going on seventeen and is brought in by her mother because she is unable to take her earrings out.  She had her ears pierced a week ago..

 

Bottom Line

  • Infection due to poor hygiene is the most common complication of ear piercings
  • The mainstay of treatment is removal of the foreign body not antibiotics
  • Infection (often with Pseudomonas spp.) is more likely in high cartilage piercings

 

What are the usual methods used in high street ear piercing?

Most high street piercers (as opposed to specialty piercing/tattooists) use a gun that fires a blunt stud through the lobe.  This is then attached to a butterfly to keep the earring in place. Professional piercers use a hollow needle to form a track for the stud.

 

What are the potential complications?

Early infection is common especially in children who may not be as fastidious as teenagers with hygiene.  Lobe piercings may become infected leading to oedema and swelling around the retaining butterfly.  Higher piercings through the cartilage are at risk from perichondritis.  Both may lead to later piercing-related keloid formation.

Nickel alloy piercings can lead to contact dermatitis.

A piercing is also a great handle for bullies to grab and rip out.

Sounds like Krystal has a retained butterfly, how do you go about releasing it?

The technique is essentially the same no matter what the age.  The challenge is providing adequate pain relief and/or sedation to an inflamed ear.  Younger children respond well to topical EMLA with adjunctive nitrous, whereas older children may need only need some EMLA and ice.  Very occasionally true procedural sedation is required.

Using sterile technique identify the point where the back of the butterfly is nearest the surface of the skin on the back of the lobe and make a small nick.  Then push on the front of the lobe to expose the butterfly, like shelling a pea.  You should then be able to remove the backing without difficulty.  There may be a small amount of bleeding that can be covered with a sticking plaster.

Addendum 20/4/2019

Thanks to @babydocmacski for this suggestion

 

What is perichondritis?

High piercings can lead to infection of the cartilage and overlying soft tissue with possible disfiguring abscess formation.  The commonest organisms involved are Pseudomonas  and Staph. aureus.

 

How do you treat it?

They may require IV anti-pseudomonal antibiotics (such as piperacillin/tazobactam) as well as the removal of the foreign body.

 

What advice would you give Krystal (and her parents) about getting her ears pierced again?

She should wait until the wound has healed and choose an alternative site, ideally done by a professional piercer and be meticulous when it comes to hygiene.

 

Outcome

Krystal screams when you try to remove the butterfly under nitrous so you elect to perform procedural sedation using intravenous ketamine and EMLA.  Whilst adequately sedated and no longer wriggling, you manage to pop the butterfly out without further fuss.

 

Selected references

“High” ear piercing and the rising incidence of perichondritis of the pinna Junaid Hanif, Adam Frosh, C Marnane, K Ghufoor, R Rivron, G Sandhu BMJ. 2001 April 14; 322(7291): 906–907

Fijałkowska M, Pisera P, Kasielska A, Antoszewski B. Should we say NO to body piercing in children? Complications after ear piercing in children. Int J Dermatol. 2011 Apr;50(4):467-9

Timm N, Iyer S. Embedded earrings in children. Pediatr Emerg Care. 2008 Jan;24(1):31-3

Do antibiotics affect CSF results?

Cite this article as:
Tessa Davis. Do antibiotics affect CSF results?, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3997

Paediatricians often have to make a decision about whether to just go ahead and give antibiotics in suspected meningitis, or wait for a lumbar puncture (LP) – this could be due to parental refusal, an unstable patient, or a failed attempt.

There is often a discussion about repeating the LP later that day, or even the following day. We all know that having had antibiotics might affect the results. But what effect does it actually have?

Here, I summarise three key papers looking at this very question – do antibiotics affect cerebrospinal fluid (CSF) results in bacterial meningitis?

Paper 1 - Michael et al (2010)

View paper

Who were the patients?

Patients were adults from a large UK district hospital and were identified retrospectively through a coding diagnosis of meningitis.

 

How was bacterial meningitis defined for inclusion criteria?

Patients had to have clinical features consistent with meningitis and had to have had an LP with a cell count of >4 cells/ml.

 

How many patients were included?

They had 92 patients included in the study.

They had been diagnosed with meningitis and had an LP with >4 cells/ml.

They all received antibiotics prior to the LP.

 

What did they find?

What they concluded from the analysis was that once antibiotics have been started, an LP within 4 hours of antibiotic administration is still likely to be culture positive.  After the 4 hour mark the proportion of positive CSF cultures dwindled. 

Paper 2 - Kengaye et al (2001)

View paper

Who were the patients?

The cohort was drawn from all patients discharged from San Diego Children’s Hospital during a 4 year period.

The patient group was identified by a coding diagnosis of bacterial or suspected bacterial meningitis.

 

How was bacterial meningitis defined for inclusion criteria?

CSF culture positive with bacteria; CSF WCC >10/mm3 + CSF antigen or Gram stain positive; CSF WCC >100/mm3 + blood culture positive; or CSF WCC >4000/mm3 in the absence of positive cultures.

 

How many patients were included?

There were 128 patients included.

43% had an LP both pre- and post-antibiotics, 30% had antibiotics prior to LP, and 27% had LP prior to antibiotics.

 

What did they find?

There were far less positive CSF cultures in post-antibiotic LPs.

In particular N. meningitides was sterilized earlier than Strep. penumoniae or Group B Strep. meningitis.

No N. meningitides CSF cultures were positive by 2 hours post-antibiotics.

Their conclusion was that negative cultures occurred in 44% of post-antibiotic LPs and only 8% of pre-antibiotic LPs.  And that meningococcal meningitis is very quick to sterilize.

Paper 3 - Nigrovic et al (2008)

View paper

Who were the patients?

This was a retrospective cohort study across twenty Emergency Departments in US paediatric centres.

Paediatric patients were identified through a coding diagnosis of bacterial meningitis or unspecified meningitis; and a review of positive CSF cultures for bacteria.

 

How was bacterial meningitis defined for inclusion criteria?

CSF culture for positive for a bacterial pathogen; CSF WCC >=10 cells/microL with positive blood culture +/- positive CSF agglutination study results.

 

How many patients were included?

245 patients were included.

159 (65%) had the LP before antibiotic treatment and 85 (35%) had the LP after antibiotic treatment.

Of those who had received treatment prior to LP: 24% had oral antibiotics; 69% had IV antibiotics; 7% had both oral and IV antibiotics.

 

What did they find?

CSF culture results were significantly more likely to be negative after receiving antibiotics.

4 hours post-antibiotics: CSF WCC was not affected by the administration of antibiotics; but the CSF glucose was significantly higher; and the CSF protein lower (although not significantly).

This was more marked (and more significant) 12 hours post antibiotics.

What should we take from this for our daily practice?

I find it hard to draw any useful conclusions from the Benedict et al study. There are three major flaws with it:

  1. Every single patient had antibiotics before having their LP.  There is no comparison to the group that had the LP first (apparently there were none in this category) and so to draw any conclusion about the effect of the antibiotics on the CSF results seems a stretch.
  2. Patients were actually excluded if their CSF had <5 cells/ml and the culture was negative.  This seems to hugely skew the results.  It could be that there were thousands of (excluded) patients who had antibiotics prior to LP and that all their CSF sample showed no WCC and were culture negative.  This would vastly change the results.  It’s also in adults which makes it difficult to draw paediatric conclusions.
  3. The patients were split into viral and bacterial meningitis groups, and part of the way this decision was made was by looking at the CSF results.  It’s self-fulling spiral.

But, it is fair to say that in the patient group they looked at, the CSF cultures were still positive even after antibiotic administration as long as it was within 4 hours.  By the time there was an 8 hour gap post-antibiotics, none of the CSF cultures were positive.

All the studies were retrospective and relied on correct coding diagnosis.  The retrospective nature also made it difficult to accurately assess timing of lumbar puncture and antibiotics administration.  Deciding the inclusion criteria for bacterial meningitis in a study about the effect on CSF results is fraught with difficulties.

Kanageye’s paper, however, does indicate that CSF culture results are affected by antibiotic administration (even within a couple of hours) and so repeating the lumbar puncture the following day may well give false reassurance. And Nigrovic’s paper reinforces this finding, and adds that CSF glucose will increase, and CSF protein will decrease, post antibiotics (especially 12 hours post antibiotics).

Although the accuracy of the timing measurement is potentially flawed, this is something to bear in mind.  Often in paediatrics the LP is unsuccessful, the patient is treated anyway, and the LP will be repeated the following day.  This can give falsely reassuring results.  Be wary of making decisions around length or choice of antibiotic, based on a post-antibiotic lumbar puncture

 

References

Michael B, Menezes BF, Cunniffe J, Miller A, Kneen R, Francis G, Beeching NJ, Solomon T. Effect of delayed lumbar punctures on the diagnosis of acute bacterial meningitis in adults. Emerg Med J. 2010 Jun;27(6):433-8. 

Kanegaye JT, Soliemanzadeh P, Bradley JS. Lumbar puncture in pediatric bacterial meningitis: defining the time interval for recovery of cerebrospinal fluid pathogens after parenteral antibiotic pretreatment. Pediatrics. 2001 Nov;108(5):1169-74.

Nigrovic LE, Malley R, Macias CG, Kanegaye JT, 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, Kuppermann N;American Academy of Pediatrics, Pediatric Emergency Medicine Collaborative Research Committee. Effect of antibiotic pretreatment on cerebrospinal fluid profiles of children with bacterial meningitis. Pediatrics. 2008 Oct;122(4):726-30.

 

 

Peri-orbital vs orbital cellulitis

Cite this article as:
Andrew Tagg. Peri-orbital vs orbital cellulitis, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3415

6-year-old Chardonnay is brought to the emergency department by her mother.  Two or three days ago she noticed what appeared to be a bite on her daughter’s eyelid.  Despite warm compresses her eyelid has become progressively more red and inflamed with the swelling now extending onto her cheek.

Traumatic brain injury - helmet

Traumatic brain injury

Cite this article as:
Adam Bartlett. Traumatic brain injury, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3381


An 8 year old boy is rushed into ED following a fall from a fourth story window.  He landed on concrete and has obvious signs of external damage to his skull and a GCS of 5.

He’s clearly sustained a serious traumatic brain injury – how is this best managed?

Minor burns

Cite this article as:
Andrew Tagg. Minor burns, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3266

Jasmina, a five old girl, is brought in by her mother after a Sunday afternoon barbecue.  Having had very little for breakfast she became very excited when the burgers came out and reached out to grab one from the grill burning her hand.

 Bottom line

  • Simple first aid is often forgotten and cold running water for at least 20 minutes may be effective up to 3 hours after the burn.
  • Grading the severity of a burn can be tough.  It is easy for experts to get it right in retrospect.
  • Follow local guidelines with regard to wound management (de-roofing blisters) and dressing choice.
  • Don’t forget tetanus prophylaxis in non-immunized children.
  • Although not mentioned in this article always ask yourself if the burn could be a sign of non-accidental injury.

What immediate first aid should be done at home BEFORE coming to the ED?

Whilst grandmothers may advocate using butter, turmeric or Tiger balm the most important thing to do is…To hold the hand under cool running water for at least 20 minutes. If this has not been done prior to presentation and the patient is seen within 3 hours then this should be done in the emergency department. If they don’t have access to cold running water then immersion in cool water may be of some benefit.

Victoria Ambulance and a number of first aid kits use Burnaid®, a hydrocolloid dressing impregnated with melaleuca oil as their primary dressing. It helps keep the burn moist, is easy to take down so everyone can take a look at the burn and, most importantly, it smells nice.

What burns should be referred to a regional burns centre?

Other than large area burns and inhalation injuries the following should be discussed with your local experts…”

  • Burns to special areas e.g. face, hands, feet or perineum
  • Full thickness burns > 5% TBSA
  • Electrical burns
  • Chemical burns
  • Circumferential burns of the limbs or chest
  • Burns as a result of suspected non-accidental injury

How do we grade burns?

As nobody understands first, second and third degree burns what approach can we use?Grading depth of burn is notoriously difficult. We should all be able to pick the superficial epidermal burn or the charred full thickness burn but there is some room for error in the middle ground. Often the grade of a burn will vary depending on who is doing it and when. Often the tincture of time helps differentiate a mid dermal burn from a deeper dermal burn.

Remember, too, that the majority of burns are heterogenous and contain a number of different components. This handy, dandy table, adapted from the Victoria Burns specialists should help. Remember to measure, check capillary refill and check sensation.

How are you going to clean the burns?

Once the patient is adequately analgesed you might consider removing any adherent clothing or pre-hospital creams and unguents so you can properly assess the burn. Intranasal fentanyl or diamorphine may make this process much less distressing. One of the main aims of cleaning the burn is to prevent bacterial infection hat would delay healing.

Most burns services recommend shaving the hair of the surrounding skin because of colonisation of the hair follicles. Limb, trunk or torso burns should be cleaned with 0.1% aqueous chlorhexidine or normal saline.

There is a great deal of controversy as to whether blisters should be left intact or de-roofed. Those in favour of de-roofing suggest it is impossible to gauge the depth of the burn without visualising it. Those against suggest that the blister fluid, being sterile, acts as a cushion against shear trauma for the healing skin as well as keeping the environment moist. As always be guided by local policies.

In Victoria the regional burns service recommends removal of the blisters using a sterile technique.

How are you going to dress the burns?

Once again local policy often trumps evidence but some type of dressing depends often on depth of burn. The ideal dressing should be non-adherent, highly absorbent and have some antimicrobial properties. Non-Adherent dressings make it easier to re-examine the burn without causing undue distress to the child.  Burns with a degree of blistering also need to be able to soak up the exudate unless the patient wants to wear it on their clothes.

Superficial/epidermal – these often require nothing more than aloe vera and a stern word

Superficial dermal (partial) – these often need something to soak up the exudate such as a foam or paraffin gauze, or a more flexible silicone based dressing e.g. Mepilex

Mid dermal to deep dermal – these wounds are often heavily contaminated and the majority of burns units now favour silver based dressing such as Acticoat©. In the past silver sulphadiazine (SSD) cream was used but this tended to stick to the wound necessitating more frequent dressing changes thus impairing healing.

The silver impregnated dressing acts as an antibacterial but dries out readily and requires water (not saline) to activate it. Once the silver dressing has been applied then a second layer of moist gauze should be applied over the top followed by crepe. After 24 hours or so the dressing should auto-activate as the burn exudate keeps the dressing moist. There is no evidence that prophylactic antibiotics reduce the incidence of infection.   Evidence for the use of silver impregnated dressings in superficial dermal burns is lacking and given their high relative cost there is a move to using them only for the deeper burns.

What should the family be told about aftercare of the burn?

Parents need to know what to expect to lessen the chance of an unplanned revisit. All but the most superficial of burns should be followed up, either in a specialist burns or plastics clinic or at planned intervals in the emergency room. In this era of smartphones parents can take a picture of the healing burn at each visit in case they are seen by a different healthcare professional.

A burn often looks very dramatic when it first occurs and that does make it hard to judge depth. It is easy to make mistakes and if it looks like the wound is not healing within the expected time frame then the patient should be promptly referred to the burns service for consideration of grafting. Burn skin may be a different colour to surrounding skin, may be hyperalgesic for a period of time and is much more likely to burn if exposed to the sun. Blisters may form but they should be dealt with by healthcare professionals at the next visit rather than risk infection.

Outcome

Jasmina had some erythema to her palm and immediate blistering to her fingertips, that was incredibly painful.  It was decided that the burn was a mixture of epidermal and superficial dermal. As the burns affected the finger tips of a young child the case was discussed with the local burns service who advised individual paraffin gauze dressings.  They arranged to see Jasmina in their next clinic.

Acknowledgements Thanks to Cameron Keating SET2 Registrar Plastics & Reconstructive Surgery & Prof Roy Kimble

References

The Victorian Adult Burns Service, Alfred Health, Melbourne, Australia – https://www.vicburns.org.au/ – (accessed 29/07/2013)

Guthrie,K, Minor Burns in the Emergency Department – www.lifeinthefastlane.com (accessed 29/07/2013)

Selig HF, Lumenta DB, Giretzlehner M, Jeschke MG, Upton D, Kamolz LP. The properties of an “ideal” burn wound dressing–what do we need in daily clinical practice? Results of a worldwide online survey among burn care specialists. Burns. 2012 Nov;38(7):960-6

Aziz Z, Abu SF, Chong NJ. A systematic review of silver-containing dressings and topical silver agents (used with dressings) for burn wounds. Burns. 2012 May;38(3):307-18

Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst Rev. 2013 Mar 28

Wu C, Tan AL, Maze DA, Holland AJ. Instant hot noodles: do they need to burn? Burns. 2013 Mar;39(2):363-8

Are nebulisers or spacers better for managing acute asthma?

Cite this article as:
Tessa Davis. Are nebulisers or spacers better for managing acute asthma?, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3278

This Cochrane review was published this week and here’s my summary.

This review looks at the question:

Which is better for the delivery of salbutamol in acute asthma – spacers or nebulisers?

The full version can be read here.

 

Why is this review useful?

It’s useful because, in my experience, different hospitals have different practices with regards to the initial management of asthma in PED. In my previous hospital we gave 3 back-to-back salbutamol nebulisers (2.5mg or 5mg depending on the age/size). In my current hospital we give 3 x 20 minutely salbutamol inhalers.

 

What type of patients were included?

The studies included children being managed in ED, or in the community, wih acute asthma.

People with life-threatening asthma were excluded.

 

How many patients were included?

This review looked at 39 studies which included 1897 children.  The review also looked at the evidence in adults.

 

What were the outcomes?

Primary outcomes: admission to hospital; duration of inpatient hospital stay.

Secondary outcomes: time in ED; change in respiratory rate; blood gases; pulse rate; tremor; symptom score; lung function; use of steroids; relapse rates.

 

What were the findings for these outcomes in ED?

There was no significant benefit in using nebulisers rather than spacers to deliver beta agonists to prevent hospital admission. And, the time spent in ED was significantly shorter (mean 33 mins) with spacers.

Pulse rate after treatment was significantly lower in children who received treatment via a spacer and development of tremor was more common in children who received nebulised treatment.

There was no difference in lung function or oxygen saturation.

 

Other points to note…

The authors acknowledge the uncertainty of choosing the correct dose.  The studies generally rely on titrating the treatment to the response of the patient and repeating doses as necessary.  This is good advice for real life.

The type of spacer did not affect the outcome.

The studies compared inhalers to separate nebulisers (not continuous). In practice, many hospitals use continuous nebulisers which is thought to be more effective than separate nebuliserss as it avoids rebound bronchoconstriction.

 

Main Conclusion

“Metered-dose inhalers with a spacer can perform at least as well as nebulisation in delivering beta-agonists in children with acute asthma”

Salbutamol has systemic side effects – tremor and increased pulse rate were more common when using nebulisers.

 

Post circumcision bleeding

Cite this article as:
Andrew Tagg. Post circumcision bleeding, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3159

Sam, a 9-day old boy, is rushed into the paediatric emergency room by his distraught parents.  Bright red blood is soaking through the front of his cloth nappy.

 

Bottom Line

  • The incidence of neonatal circumcision is on the decline though it may still be performed for religious reasons.
  • Circumcision reduces the transmission of HIV and HPV and reduces the risk of UTI’s.
  • The commonest complications are pain, bleeding and later infection.

 

What is a bris?

A brit milah, or bris, is the traditional Jewish circumcision ceremony that usually takes place on the 8th day of life.  It is carried out by a mohel. The mohel may not be a medical practitioner.  Followers of Islam are also circumcised (Khitan) though there is no prescribed time after birth in which must take place as long as it is before the age of 10.

What proportion of newborn boys are circumcised?

Whilst a number of religions including Islam and Judaism require newborn boys to be circumcised the proportion of boys that undergo the procedure is declining.  Currently, about 10-20% of boys born in Australia and less than 10% in New Zealand are circumcised.

The Royal Australasian College of Physicians’ policy statement on male circumcision states that “there is no evidence that the benefits outweigh the risk of the procedure”. The American Academy of Pediatrics holds the opposite view.

 

Other than religious reasons, why might a boy be circumcised?

  • Treatment of true phimosis
  • Prevention of recurrent balanoposthitis
  • Prevention of recurrent UTI’s
  • Prevention of STI transmission

A 2009 Cochrane meta-analysis found that male circumcision in sub-Saharan Africa reduced male-to-female rates of HIV transmission by 36-66%. Males who have been circumcised are unlikely to pass on HPV to their partners in life and will not get skin cancer of the penis.

 

Are there any contraindications to circumcision?

It is generally contraindicated if there is any genital developmental abnormality such as hypo- or epispadias or if the patient has ambiguous genitalia.  It is also not recommended in the children of parents with haemophilia until the child has been tested. It goes without saying that it should not be performed on the sick or jaundiced infant either.

 

What are the possible acute complications of such a circumcision and how would you treat them?

  • Pain
  • Bleeding
  • Infection

Complications occur following approximately 1 in 500 procedures. The tip of the penis is often crusted and inflamed. Sucrose should be used prior to the removal of the dressing in the neonate.

If there is profuse bleeding this may be a marker of an underlying coagulopathy and so should be tested for.  Bleeding may be due to a snipped vessel or localized inflammation/infection.  Direct pressure with a surgical dressing such as Kaltostat should halt the bleeding. Very rarely a single suture is needed to tie off a bleeding vessel.

Should there be any cellulitis to the penis in the neonate then they should be admitted for IV antibiotics.

 

Outcome

Once the nappy was removed it was obvious that there was active bleeding to the area where the foreskin had been removed.  After giving some sucrose the vaseline gauze dressing was removed and a bleeding point identified.  When the application of a surgical dressing failed to stop the bleeding a penile block was placed and a single stitch tied off the guilty blood vessel. The clotting profile was normal and Sam was discharged to follow up with his primary care provider.

 

References

Royal Australasian College of Physicians, Paediatrics & Child Health Division. Circumcision of infant males. [cited 2013 Jul 22]

American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics. 2012 Sep;130(3):e756-85.

Siegfried N, Muller M, Deeks JJ, Volmink J. Male circumcision for prevention of heterosexual acquisition of HIV in men. Cochrane Database Syst Rev. 2009 Apr 15;(2).

Anaphylaxis and dosing errors

Cite this article as:
Tessa Davis. Anaphylaxis and dosing errors, Don't Forget the Bubbles, 2013. Available at:
https://doi.org/10.31440/DFTB.3113

Medication errors are a particular area of interest for me, so this paper caught my eye….here’s my summary of it.

 

It’s a paper by Benkelfat et al and is published in the September 2013 issue of the Journal of Emergency Medicine.

 

Benkelfat R, Gouin S, Larose G, Bailey B. Medication errors in the management of anaphylaxis in a pediatric emergency department. J Emerg Med. 2013 Sep;45(3):419-25.

 

It looked at using standard order forms to reduce medication errors when managing anaphylaxis in paediatric emergency.

 

What’s the need for the study?

It may seem surprising, but most doctors do not know the correct dose of adrenaline (epinephrine) to give in the management of anaphylaxis.

Tain and Rubython (2007) showed, in a New Zealand study, that only 20% of doctors actually knew the right dose and route of administration of adrenaline for anaphylaxis.  And Drost and Narayan (2010) found that only 15% of UK doctors would give adrenaline as recommended by the UK resuscitation guidelines.  These studies were all in adults, and one would expect that in children there would be even more error due to weight variation and low frequency of presentation.

We need to be able to treat anaphylaxis quickly, safely and optimally, as patients can deteriorate rapidly and die from this.  And an overdose of adrenaline comes with its own set of side effects.

 

What was the intervention?

The authors introduced a standard order form (SOF) which was given to doctors when prescribing medications for anaphylaxis (in their Paediatric Emergency Department in Canada).

They then looked at the frequency of medication errors before introducing the SOF and after introducing the SOF.

 

How did they find the patients?

This was done retrospectively through searching for patients coded with anaphylaxis or anaphylactic shock in their ED database.  The notes were then cross-checked with the National Institute of Allergy and Infectious Disease diagnostic criteria for anaphylaxis to make sure the patients did actually have anaphylaxis.

 

How did they decide what constituted an error?

Incorrect medication dosages (10% and 25% margin of error for doses); wrong drug administration; and a delay in administration (15 min delay for adrenaline, 30 min delay for other drugs).

 

How many patients were included?

96 patients were included – 31 in the Pre-SOF group and 65 in the Post-SOF group.  In the Post-SOF group 30 patients were SOF negative – this means that even though SOF had been introduced in the department, the SOF was not used for that patient.

 

What did they find?

A whopping 60% of medication charts contained at least one medication error (59% post-SOF).

The number of dosage errors did reduce significantly when the SOF was used (this was the same using either the 10% error margin or the 25% one).

 

Perhaps most importantly for our learning, the correct adrenaline doses for managing anaphylaxis in paediatric emergency are…

Give IM doses of 1 in 1000 adrenaline into the lateral thigh (can repeat after 5 mins if not improving). Avoid subcutaneous administration and do not use IV bolus adrenaline unless cardiac arrest is likely.  Nebulized adrenaline can be used as adjunctive therapy (to IM) but not as 1st line.

Dosing can be 0.01ml/kg of 1 in 1000, or if it is easier to remember:

  • <6 years old: 150mcg (0.15 mL) IM
  • 6-12 years old: 300mcg (0.3 mL) IM
  • >12 years old: 500mcg (0.5 mL) IM
  • Adult: 500mcg (0.5 mL) IM

 

References

Thain S, Rubython J. Treatment of anaphylaxis in adults: results of a survey of doctors at Dunedin Hospital, New Zealand. N Z Med J, 2007;120:1252.

Droste J, Narayan N. Hospital doctor’s knowledge of adrenaline (epinephrine) administration in anaphylaxis in adults is deficient. Resuscitation 2010;81:1057–8.

Anaphylaxis guidelines, Royal Children’s Hospital, Melbourne.