Mandible Injuries

Cite this article as:
Helen Nightingale. Mandible Injuries, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21585

A fifteen year old named Jason limps into A&E at midnight with a black eye, a split lip, and pain in his jaw, worst around the left angle of the mandible. He is guarded about what has happened to him. He is reluctant to give his full name or for his parents to be called. You smell cigarettes on his clothing and you wonder if he might be intoxicated. He says it is numb when he touches his chin but it was really painful when he tried to eat some crisps in the waiting room.

Maturing your approach to trauma: Anne Weaver at DFTB19

Cite this article as:
Team DFTB. Maturing your approach to trauma: Anne Weaver at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22196

Anne Weaver is a consultant in Emergency Medicine & Prehospital Care at The Royal London Hospital and Lead Clinician for London’s Air Ambulance. In this talk she shares her experience of caring for the ever-increasing number of stabbing victims in the United Kingdom. 


There is a disconnect between what adult trauma surgeons and paediatric trauma surgeons are exposed to and are expected to manage. Just one year shy of 16 and the paediatric surgeon, who may never have performed a paediatric thoracotomy, is looking after you, one year over and it’s the adult trauma surgeon with many a notch on their Finochietto.

©Ian Summers

 

DoodleMedicine sketch by @char_durand 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. 

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Triplane ankle fractures

Cite this article as:
Anna O'Leary. Triplane ankle fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23578

Sean is 13 years old. He was playing basketball but when he jumped to score a basket he landed awkwardly on his ankle, twisting and externally rotating it. He immediately fell to the floor on the court and couldn’t weight bear on it. The swelling and bruising increased and he attended his local emergency department where he was told that he had a triplane ankle fracture.

 

Epidemiology

Although triplane ankle fractures account for only 5-15% of overall paediatric ankle fractures, along with Tillaux fractures, they are the most common ankle fractures in adolescents. This type of fracture represents a unique spectrum of injury that does not fit neatly into the Salter-Harris classification of physeal injury. They occur before complete closure of the distal tibial physis (hence why they occur in adolescents whose epiphyseal plates are closing) and are classically seen in 10-17 year olds. They are slightly more common in males.

 

History

Adolescents with triplane fractures will usually present to the emergency department with a very painful and swollen ankle after a twisting force to the leg during athletic or recreational activities. They are usually very reluctant or unable to weightbear.

 

Examination

There will often be swelling and bruising with focal or referred pain at the affected ankle. There may be deformity of the ankle. It is important also to examine skin integrity and the presence of neurologic defects or vascular injuries. Don’t forget to palpate the full length of the fibula to evaluate for a proximal fracture as well as along the foot to evaluate for injuries such as a fracture to the base of the 5th metatarsal.

 

Investigations

AP and lateral ankle xrays will help evaluated the fracture type. Addition of a mortise view, performed with the leg internally rotated approximately 15 degrees to allow better assessment of the articular space, should be included to assess the amount of displacement if this can’t be fully appreciated on the AP view (although in some countries the AP view is a mortise view).

The triplane fracture on x-ray looks like a Salter-Harris II or III depending on whether this is a medial or lateral triplane fracture. The fracture is in all three planes, classically looking like a Mercedes sign on CT.

 

Triplane Mercedes sign. From Orthobullets

 

It may be classified as in 2, 3 or 4 parts.

 

It is important not to miss fibular fractures which are seen in 50% of triplane fractures. Typically this is a spiral fracture pattern located proximal to the physis in children nearing skeletal maturity.

CT scans are not routinely performed in the emergency department but may be organized by the orthopaedic team. Small dislocations and the vertical component of the fracture are not infrequently overlooked. CT is therefore often organized to fully delineate fracture pattern and to assess the degree of intra-articular congruity.

 

Management

In the ED, as with any injury, ensure you prescribe adequate analgesia and provide assistance with non-weight bearing status, such as a wheelchair or crutches depending on the ability of the child. Placement in a boot or cast for comfort prior to definitive treatment by the orthopaedic team is appropriate.

Once the diagnosis is made, ongoing care depends on the degree of displacement. Orthopaedic review for consideration of conservative management versus operative management is important as these fractures will often need CT imaging to ensure adequate delineation of fracture pattern.

 

Conservative management

Fractures with minimal displacement (<2mm), particularly if they are 2 part triplane fractures, can often be managed with closed reduction and casting. If the fracture is in 3 or 4 parts, closed reduction is difficult to achieve.

Post reduction, place in a long leg/above knee cast for 3-4 weeks to control the rotational component of the injury, followed by a further 2-4 weeks in a short leg cast or walking boot to initiate ankle range of movement.

 

Operative Management

Any triplane fracture with >2mm displacement or that is in 3 or 4 parts is likely to require ORIF (Open Reduction, Internal Fixation). Intra-articular reduction to within 2 mm is required for optimal treatment of these unique paediatric ankle fractures.

A CT showing triplane fracture requiring ORIF with >2mm of displacement. You can clearly see why the fracture is called triplane, as it extends in 3 planes: coronal, sagittal and axial. Image from Orthobullets

 

Complications and Risks

  • Growth Arrest:

The main concern in an adolescent with a triplane fracture is growth arrest. This occurs in between 7-21% of triplane injuries. This is often insignificant but does mean that patients with more than 2 years of growth remaining must be closely followed up.

  • Ankle Pain and Degeneration:

Rare but increased risk with articular step greater than >2mm.

 

Controversies

As with all things orthopaedic, the debate continues: should these fractures be managed operatively or conservatively? Though still in preliminary research stages, recent evidence suggests that non-operative treatment of triplane fractures may have comparable clinical and radiographic results to operative treatment. Discussion with the orthopaedic team is advised prior to discharge given the different management options.

 

Things not to miss!

Don’t forget to examine the rest of the child’s lower limb when they present with a painful swollen ankle as there may be an associated accompanying fracture. Ensure that you examine and especially palpate both the foot and the entire length of the fibula. With rotational forces, proximal spiral fibula fractures and base of 5th metatarsal fractures are relatively common with triplane fractures. Carefully check and document neurovascular status as nerve injury can occasionally be associated with spiral fibular fractures.

Triple fracture with accompanying spiral fibula fracture. From Orthobullets

 

Sean was found to have a 2 part nondisplaced Triplane Fracture and was placed in an above-knee cast and followed up at his local orthopaedic outpatient clinic. He had interval x-rays which showed good healing and no evidence of displacement. After 4 weeks he was switched to a walking boot to encourage early ankle mobilization for another 2 weeks. He is looking forward to next year’s basketball season already!

 

References

Schnetzler, Kent A et al 2008 ‘The Pediatric Triplane Ankle Fracture’ The Journal of the American Academy of Orthopaedic Surgeons 15(12):738-47

Hyman et al, MSK Key https://musculoskeletalkey.com/transitional-ankle-fractures-juvenile-tillaux-and-triplane-fractures/ Accessed at 09/02/20

Beaty JH, Kasser JR. Rockwood and Wilkins’ Fractures in Children. 6th ed. Baltimore, MD: Lippincott Williams & Wilkins; 2006:1105

https://orthoinfo.aaos.org/en/diseases–conditions/ankle-fractures-in-children/

Min Ryu, Seung et al 2017 ‘Is an operation always needed for pediatric triplane fractures?’ Journal of Pediatric Orthopaedics B 27(5):1 · November 2017

https://www.orthobullets.com/pediatrics/4029/triplane-fractures

https://orthoinfo.aaos.org/en/diseases–conditions/ankle-fractures-in-children/

Paediatric analgesia and pain assessment

Cite this article as:
Ciara Murphy. Paediatric analgesia and pain assessment, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23666

Jamie is a 3-year-old boy who presents to the emergency department. He was playing with his 5-year-old brother on the trampoline and fell off. He is very distressed and crying in triage but his mum doesn’t know where he hurt himself. She had rushed to the department with him and so hadn’t given him any prehospital analgesia. Mum herself also appears very anxious and worried.

 

Pain assessment and management in the paediatric population is a challenging area, and it is something that we often get wrong.   Children’s pain is historically poorly measured and often undertreated because children may not exhibit the common signs and symptoms of pain that we come to expect from adults.

Pain is multifactorial. In children, it is important to not just focus on the injury but the age and developmental stage of the child, the circumstances of the presentation to ED, the behavior of the parent/caregiver and the child’s interaction with them.

In the case of James, his mum appears very anxious about his injury. Children tend to feed off of their parent’s anxiety and become more distressed. Moving them to a quiet area for assessment and reassuring mum that they are in the right place and that you’re going to take great care of James is an ideal starting point. Hopefully, reassuring and calming his mum will go some way to diffusing the situation, and calming James also.

 

Pain assessment

Assessment of a child in pain varies greatly with their age and developmental stage. This is one of the most important things to take into account during your encounter. If the wrong tool is used, the pain may be underestimated and the child under-treated. The longer the time to proper pain relief, the more distress there is for both child and parent, and so the spiral continues.

 

Neonates and infants (0 – 2 years)

For the youngest, the FLACC (Faces, Legs, Arms, Cry, Consolability) scale can be useful. This scale comprises of five components. The child needs to be observed for at least a minute. A child of this age isn’t going to be able to tell you much about their pain, so you need to rely heavily on your observational skills. Involving the parent in the assessment is  key.

Context is very important in this group also, particularly for the one-year-old who seems very distressed in triage or when being examined by the strange doctor but is more settled in mum’s lap. Frequent reassessments are therefore extremely important and beneficial.

 

Toddlers and preschoolers (2 – 4 years)

In this group, developing a rapport is a must in order to be able to accurately assess the level of pain. Get on the child’s level, use a soothing friendly voice, employ some ice-breaking chat.

Ask open-ended questions, don’t just palpate areas and say “Does this hurt?” – as you may well get a yes in every area – e.g. “Can you show me where is sore? Can you point to what is hurting you?

For these slightly older children, the Wong-Baker faces scale is great. These can be produced in bright colours to make them fun  and to aid with their participation in the assessment.

 

 

This scale has been validated in children aged 3 and up, but in practice it is often used in those over 2. The child is shown the faces and asked to point to the one that best represents how they are feeling.

Again, reassessment after initial analgesia using the same scale/method of assessment is important.

 

School-aged children (4 – 16 years)

As the child develops verbally, the assessment of their pain should become easier. For children aged 4-8  years of age, the Wong-Baker faces scale is probably still the most appropriate tool to use. In the older child, you can use the numerical pain ladder.

This can be either a visual representation where you ask them to draw a line or indicate where their pain falls on a physical scale, or you can simply ask them to give their pain a score out of 10 without showing them the scale.

 

 

You move James and his mum to the minors area to complete his assessment. Mum is now calmer, and this seems to have settled James somewhat. He is no longer crying, but he is still grimacing and he appears to be holding his left elbow fixed in flexion. You ask him point to where it is sore and he indicates his left arm. He refuses to move it. A survey of the rest of his body doesn’t reveal anything else concerning, he is fully weight-bearing and is moving his neck and right arm without issue. On palpation and careful examination of the left arm he is very distressed when his elbow is touched, and it appears to be swollen. You show him the Wong-Baker scale and he points to the orange sad face, which indicates a pain score of 8.

 

Pain management

To achieve the best pain management for our patients, we first have to have a basic grasp of pain physiology.

Nocioceptive pain follows a sequence where 4 events take place:

Pain transduction – a painful stimulus eg trauma causes tissue damage – this leads to the release of chemical mediators in the tissue, e.g. prostaglandins/substance P etc. These trigger an action potential.

Transmission – the action potential moves along the nerve fibres, travelling from the peripheral site of injury to the spinal cord.

Perception – the action potential travels along the spinothalamic tract to the brain, where it is relayed to the areas involved in pain perception (limbic system, somatosensory cortex, parietal and frontal lobes)

Modulation – the midbrain releases endorphins/serotonin etc to mitigate pain

We can target each part of the sequence in our treatment of pain, as long as we remember that analgesia is multi-modal, and does not just revolve around drugs.

 

 

Transduction

We can intervene at this stage by employing basic first aid measures – for example

  • If the child has a burn – run it under cool/room temperature water. This will provide pain relief as well as arresting further tissue damage
  • If a limb is obviously deformed or clinically has a fracture – splint or backslab the limb during your initial assessment and before sending the child for x-rays
  • If there is a suspicion of a clavicular or shoulder injury give the child a sling
  • If they have a swollen area ?soft tissue injury e.g. ankle – place an ice pack and get them to elevate the ankle.

These things may seem like common sense, but all too often they are forgotten in favour of pharmacological interventions which will not have as immediate an effect.

 

Perception

A child can be distracted much more easily than an adult, and we need to use this to our advantage in the context of pain management. Employing distraction techniques can affect and reduce a child’s perception of pain.

There are many options available and you can get the parents involved also. Distraction techniques obviously vary in their effectiveness depending on the age of the child, but they include: story-telling; singing a song (I can’t be the only one that hears Baby Shark as they fall asleep at this point!); balloons; stickers; bubbles; playing a video on a smartphone.

For older children, guided imagination can be used to great effect, particularly before procedural sedation with nitrous oxide or ketamine. Letting them listen to their own music on their phone via earphones is also a good idea. Some departments are now looking at the role of virtual reality headsets for older children undergoing painful procedures which appears to be a very successful method of distraction.

 

Transmission

Pharmacological agents act to interrupt the transmission of the painful stimulus. There are many agents available, depending on the child’s age and the level of pain described.

Topical anesthetics

Ametop (4% w/w Tetracaine) and EMLA 5% (lidocaine/prilocaine) are anaesthetic creams that can be applied to intact skin, usually pre-cannulation. They numb the skin and make the procedure less painful. They are ideal in situations where a slight delay to cannulation is safe, as they need to be in situ for a while to work (Ametop 30 mins, EMLA for an hour).

LAT gel – Lignocaine 4% / Tetracaine 0.5% / Adrenaline 0.1% is an anaesthetic gel. It comes in a single-use bottle. It is designed for use on broken skin, and so it should be ideally applied to wounds/lacerations in triage and left in situ for 30. It numbs the area and allows for thorough cleaning, proper assessment, and closure of wounds while reducing the need for injectable local anaesthetic in a lot of cases.

Contraindications

  • ANY previous reaction to local/ general anaesthetic or known cholinesterase deficiency
  • Wound on or near mucus membrane including eye, nose or mouth.
  • Wound > 5 cm in length
  • Concern about tissue viability i.e. crush or flap wounds
  • Wounds over 8 hours old
  • Obvious injury to associated structures i.e. bone, tendon, blood vessels, joint or nerve
  • Wounds to the ear, nose, genitalia or digits should be discussed with a registrar before using LAT gel. This is due to concerns about perfusion and also due to evidence showing less effect on extremity wounds.

 

Paracetamol

This is perhaps best known to parents as Calpol (UK and Ireland), Panadol or Crocin (Australia) or Tylenol (in the States), however, there are other brand names. There are two different preparations of Calpol depending on age (120mg/ 5mls or 250mg/5mls) so make sure to clarify what the parent has at home.

Paracetamol can be given PO/PR/IV but is most commonly given orally. The dose is 15mg/kg to a maximum dose of 1 g.

It can be given 4-6 hourly, but to a maximum of 4 doses in 24 hours. It takes approximately 30 minutes to work

Overdose is 75mg/kg (although toxicity usually doesn’t occur until >150mg/kg in an acute ingestion or repeated supra therapeutic doses>100mg/kg). If this happens it can cause hepatic necrosis – so bloods will need to be checked and if the paracetamol level is beyond a certain threshold the child will need to be started on n-acetyl cysteine.

 

Ibuprofen

Ibuprofen is a non-steroidal anti-inflammatory (NSAID) that is available over the counter. NSAIDs work to stop the inflammatory cascade of chemical mediators and thus reduce inflammation and pain. It is also an anti-pyretic.

It is commonly sold as Nurofen (in the UK, Ireland and Australia) and Advil (in America) but again has other brand names as well as being sold by generic name. Nurofen also comes in two preparations (100mg/5mls or 200mg/5mls) – always clarify with the parents as to what they have at home to ensure appropriate dosing.

Ibuprofen can be given at a dose of 10mg/kg to a max of 400mg 8 hourly. An overdose obviously isn’t desirable but does not carry the same dangers as paracetamol.

It can be given PO or PR, however the suppositories only come in 60mg so are not as useful in bigger children.

Always, always double-check which medicine a parent may have given at home. For example, Calpol contains paracetamol but Calprofen contains ibuprofen – you can see how double doses can accidentally be given in the emergency department soon after a child presents.

 

Diclofenac

Diclofenac also a member of the NSAID family. It can be used in place of ibuprofen in the older child in its oral form.

In my own practice PR diclofenac suppositories have been invaluable in the pain management of infants with stomatitis or bad tonsillitis causing distress and poor oral intake, while also controlling their pyrexia.

The dose is 1mg/kg 8 hourly (max 50mg per dose) and can be given PO/PR.

Max dose is 3mg/kg in 24 hours.

 

Morphine

Morphine is a strong natural opioid. It is used for severe pain, or pain that is not responding to first-line analgesics. It can be given by a variety of routes, but most commonly PO or IV.

Oramorph is an oral form of morphine, available in liquid preparation and is dosed by age band:

  • <1 year: 80 -200mcg/kg
  • 1-2 years:200-400mcg/kg
  • 2-12 years:200-500mcg/kg
  • 12-18 years: 10-15mg

Its IV dose is 0.1mg/kg. It can be given prn usually every 4-6 hours

Potentially serious side effects include decreased respiratory effort and low blood pressure. Overdose treatment includes the administration of naloxone (0.1mg/kg IM or IV).

 

Fentanyl

Fentanyl is a strong synthetic opioid with a faster onset / offset than morphine, starts to work within 7 minutes. It’s great for initial analgesia for fractures/dislocations, burns, major lacerations.

The loading dose is 1.5mcg/kg and can be repeated after 20-30 minutes

Side effects are uncommon, but may include respiratory depression/hypotension/nausea and vomiting. It is given intranasally (IN) with an atomizer device and has great mucosal uptake without having the need for IV access.

 

Diamorphine

Diamorphine is also an opioid that can be given intranasally as an alternative to fentanyl, using an atomizer device.

The dose is 0.1mg/kg IN

It carries the same potential side effects as morphine and fentanyl, but has been shown to be very safe at this dose in the paediatric population.

 

Methoxyflurane

Methyoxyflurane is also known as Penthrox / the green whistleIt is an inhaled medication primarily used to improve pain following trauma. Each dose lasts approximately 30 minutes.

Pain relief begins after 6–8 breaths and continues for several minutes after stopping inhalation

It is self-administered to children and adults using a hand-held inhaler device

 

The STOP trial looked at its safety and efficacy in adults and children >12 and found that it was safe and worked well. It is currently being investigated in those aged 6-18 in the MAGPIE trial, which is still undergoing data collection.

 

Procedural sedation

Sometimes, analgesia alone isn’t enough. If a child has a deformed fracture for example that needs to be manipulated, they will need procedural sedation. This is usually achieved with wither nitrous oxide or ketamine, depending on the child’s age and the procedure required.

 

You suspect that Jamie has a fractured arm, perhaps a supracondylar fracture. His weight is 18kg. Given his level of distress and pain score of 8, you give him both IN fentanyl 27mcg and paracetamol 270mg. Mum plays a video on her phone for him while you apply an above elbow backslab to splint and immobilize his arm before he goes to x-ray.

You reassess him after these interventions and he looks much happier, you even get a smile. He indicates the second green face on the Wong-Baker scale, equating with a pain score of 2. He goes for an x-ray which confirms a supracondylar fracture – Gartland 2. 
You refer him to the orthopaedic team for admission and management. You ensure that he has regular analgesics as well as PRN extras written up in his drug Kardex before he leaves the department to go to the ward.

 

References

Srouji R, Ratnapalan S, Schneeweiss. Pain in Children: Assessment and Nonpharmacological Management. International Journal of Pediatrics. 2010. doi:10.1155/2010/474838

https://pemplaybook.org/podcast/pediatric-pain/

Manwarren R and Hynan L. Clinical Validation of FLACC: Preverbal patient pain scale. Pediatric Nursing. 2003; 29(2):140-6

Keck JF et al. Reliability and validity of the Faces and Word Descriptor Scales to measure procedural pain. J Pediatr Nurs. 1996;11(6):368-741996

Tomlinson D et al. A systematic review of faces scales for the self-report of pain intensity in children. Pediatrics. 2010;126(5):e1168-98. doi: 10.1542/peds.2010-1609

Horeczko T. “Acute Pain in Children”. In Management of Pain and Procedural Sedation in Acute Care. Strayer R, Motov S, Nelson L (eds). 2017.  

Knight K, McClenaghan CE, Singh B: Virtual reality distraction from painful procedures in the paediatric emergency departmentArchives of Disease in Childhood 2019;104:204-205.

Leicester Children’s Hospital clinical guideline. Use of Topical Wound Anaesthetic- LAT gel in the PED. Rowlands. Feb 2014.  https://static1.squarespace.com/static/546e1217e4b093626abfbae7/t/59cba0aa12abd9d55c449106/1506517164347/Topical+Wound+Anaesthetic+-+LAT+Gel+UHL+Paediatric+Emergency+Guideline.pdf

Royal Children’s Hospital Melbourne clinical guideline. Management of paediatric paracetamol overdose. https://www.rch.org.au/clinicalguide/guideline_index/Paracetamol_poisoning/

Sharif MR et al. Rectal Diclofenac Versus Rectal Paracetamol: Comparison of Antipyretic Effectiveness in Children. Iran Red Crescent Med J. 2016;18(1): e27932

Kendall J, Maconochie I, Wong ICK, et al; A novel multipatient intranasal diamorphine spray for use in acute pain in children: pharmacovigilance data from an observational study. Emerg Med J 2015;32:269-273.

Coffey F, Wright J, Hartshorn S, et al: STOP!: a randomised, double-blind, placebo-controlled study of the efficacy and safety of methoxyflurane for the treatment of acute pain. Emerg Med J 2014;31:613-618.

Different halves of the same page: Gayle Hann and Amani Simpson at DFTB19

Cite this article as:
Team DFTB. Different halves of the same page: Gayle Hann and Amani Simpson at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22374

Gayle Hann is a paediatrician that hit the headlines for her tireless work in helping the sufferers of gang violence. She has made it her mission to engage and involve youth gang members in their own care and rehabilitation in an effort to prevent them needing to come to the hospital in the future.

Amani Simpson is now an entrepreneur and founder of Aviard Inspires but at the age of 21, he was stabbed seven times in the course of a robbery. Since then he has dedicated his life to transform the lives (and perceptions of) youths across the country.

Never have such an unlikely couple come together to make a difference. This talk, from #DFTB19, had laughs, tears, and fist-bumps aplenty. It is the feel-good story of the conference that will reaffirm the idea that people are not all bad.

 

©Ian Summers

 

 
DoodleMedicine sketch by @char_durand 
 

 

 

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

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Guillain-Barre Syndrome

Cite this article as:
Aoife Fox. Guillain-Barre Syndrome, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25051

A 2-year-old girl, Amy, attends the emergency department. Her father says that for the last 24 hours she has been refusing to walk. Prior to this, she was running amuck without difficulty. In the ED, you notice that she is now having difficulty crawling. She has no significant medical history but did have fever along with a runny nose and cough 2 weeks prior to her attendance which her parents managed with paracetamol at home.

 

What is Guillain-Barré Syndrome?

Guillain-Barré Syndrome (GBS) is a group of acute immune-mediated polyneuropathies.  It most commonly presents as an acute monophasic, paralyzing illness provoked by a preceding infection.

It is the most common cause of acute flaccid paralysis in children. The annual incidence is 0.34 to 1.34 cases per 100,000 in under the 18s, which makes it less common in children than in adults. It rarely occurs in children younger than 2 years, but when it does affect younger children because GBS is way off our radars, this can make it really tricky to diagnose. Boys are affected more often than girls.

 

What causes it?

It’s thought that an immune response cross-reacts with the myelin or axon of peripheral nerves due to molecular mimicry. Similar peptide sequences between the body’s own peptides and foreign peptides sometimes cause the immune system to get confused and attack its own tissues.  You probably knew that myasthenia gravis is due to auto-antibodies against the acetylcholine receptor but did you know that the receptor shares a 7 amino acid sequence with HSV, the herpes simplex virus? It’s thought that exposure to HSV may be the precipitant for myasthenia gravis.

Approximate 2/3 of patients give a history of an antecedent respiratory tract or GI infection. Campylobacter infection is the most commonly identified precipitant and can be demonstrated in as many as 30% of cases. Other infectious precipitants include CMV, EBV, Mycoplasma pneumoniae, and influenza-like illnesses.

Other suggested triggers include immunization, although there is no clear causal relationship several cases suggest an association, as well as one with trauma and surgery.

What about Guillain Barre and COVID?

There have been several case studies reporting GBS associated with SARS-CoV-2 during the COVID-19 pandemic. Given the small number of cases, it is unclear whether severe neurological deficits are typical features of COVID-19 associated GBS. An answer to the diagnostic conundrum of whether the respiratory compromise in COVID19-associated-GBS is due to coronavirus or muscle weakness is yet to be answered.

 

How can I recognize it?

GBS classically begins with paraesthesia in the extremities – fingers and toes –  followed by lower extremity symmetric, or modestly asymmetric, weakness that ascends up the body. In severe cases, the muscles of respiration are affected, in about 10-20% of children.

Cranial neuropathy can also occur, most commonly affecting facial nerves, causing bilateral facial weakness.

Autonomic dysfunction occurs in approximately half of children with GBS: cardiac dysrhythmias, orthostatic hypotension, hypertension, paralytic ileus, bladder dysfunction, sweating.

Physical exam typically reveals:

  • Symmetric weakness
  • Diminished or absent reflexes
  • Gait abnormalities
  • Sensory symptoms include pain, paraesthesia (reflecting nerve irritability)

Generally, children have shorter clinical courses and more complete recoveries in comparison to adults. A child’s function typically deteriorates for 2-4 weeks followed by a slow return of function over the coming weeks to months.

 

On examination, you find a quiet child who is otherwise acting appropriately. She is afebrile and the rest of her vitals are within normal limits. No bruises or rashes are observed on her skin and there is no evidence of trauma. Cardiovascular, respiratory, abdominal and ENT exams are unremarkable. Her extremities are warm and well perfused with normal pulses. There is no bony tenderness or deformities on palpation of her limbs. On neurological examination, she is moving all 4 limbs spontaneously. However, she will not bear weight or stand. Both her lower limbs are weak on exam. Her grip strength is reduced and when given a toy, it falls. Both upper and lower extremity reflexes are absent.

 

Subtypes

GBS most commonly presents in the classical way above: a mixed motor and sensory polyneuropathy with lower limb pain and ascending weakness. This is the classic Acute Inflammatory Demyelinating  Polyradiculopathy (AIDP), which accounts for 85 to 90% of cases in the developed world. But, there are a few other subtypes of GBS you should be aware of.

Acute Motor Axonal Neuropathy (AMAN), is a purely motor from of GBS, occurring mainly in Asia, Central and South America and associated with a preceding Campylobacter infection. Its clinical features are similar to AIDP, but respiratory failure is more common.

Acute Motor-Sensory Axonal Neuropathy (AMSAN) is similar to AMAN but with more sensory symptoms. The course tends to be prolonged and severe but is pretty uncommon in children.

Miller-Fisher syndrome is characterized by an external ophthalmoplegia, ataxia and muscle weakness with areflexia. It affects adults more commonly than children but should definitely be on your radar in a child presenting with cranial nerve and lower limb neurology.

 

How can it be diagnosed?

The initial diagnosis of GBS is based on the history and clinical exam – be suspicious of a child with lower limb weakness, weak reflexes and a preceding illness. Use investigations to confirm your suspicion.

CSF

CSF protein above 45mg/dL with a normal WCC count is present in 50-66% of patients in the first week after symptoms onset and ≥75% of patients in the third week. This disconnect between protein and white cells is called albuminocytologic dissociation.

Gadolinium-enhanced MRI of Spine

MRI will show contrast enhancement of the spinal nerve roots, cauda equina or cranial nerve roots. These changes aren’t specific to the GBS, but can be helpful in the correct clinical setting.

Nerve conduction studies

This is the most specific and sensitive test available for GBS, abnormal in up to 90% of cases. The test can be technically difficult in small children.

Antibodies

Antibodies against GQ1b (the ganglioside component of a nerve) are present in the vast majority of patients with Miller-Fisher syndrome.

 

In the emergency department, you send baseline bloods (FBC, U&E, LFTs and CRP) which are all normal and organize a CT head under sedation which is unremarkable. After getting consent from her parents you perform a lumbar puncture. The CSF appears clear. It has no red blood cells, 2 white blood cells and CSF glucose is within the normal limits but her protein is mildly elevated. No organisms were seen on gram stain and cultures had no growth after 5-days. You refer her to the neurology team for further investigation.

 

What else could it be?

The differential diagnosis of GBS is long.

 

Brain

  • Bilateral strokes
  • Acute disseminated encephalomyelitis
  • Acute cerebellar ataxia syndrome
  • Psychogenic symptoms

Spine

  • Anterior spinal artery syndrome
  • Compressive myelopathy
  • Transverse myelitis
  • Poliomyelitis
  • Infectious causes of acute myelitis

Peripheral nervous system

  • Chronic inflammatory demyelinating polyneuropathy
  • Critical illness polyneuropathy
  • Infection-related radiculitis (e.g. HIV, CMV, Lyme disease)
  • Thiamine deficiency
  • Toxins: biologic toxins (diphtheria), heavy metals (arsenic)
  • Vasculitis
  • Metabolic and electrolyte disorders (e.g. hypoglycaemia, hypophosphatemia)

Neuromuscular junction

  • Botulism
  • Myasthenia gravis
  • Neuromuscular blocking agents

Muscle

  • Acute inflammatory myopathies (e.g. dermatomyositis, polymyositis)
  • Acute viral myositis
  • Acute rhabdomyolysis
  • Critical illness myopathy
  • Metabolic myopathies (e.g. hypokalaemia, hyperkalaemia)
  • Mitochondrial myopathies

 

What is the treatment?

The mainstay of treatment is supportive management including close monitoring of motor, autonomic and respiratory function as well as pain management and prevention of immobility complications, such as pressure ulcers. ICU admission for mechanical ventilation will be required in 10-20% of kids. This is more likely to be needed in children with:

  • rapidly increasing weakness,
  • bulbar dysfunction,
  • bilateral facial weakness or

In addition IV immunoglobulin (IVIG) and plasmapheresis (plasma exchange) can be used in children with severe, progressive GBS (i.e. worsening respiratory status or need for mechanical ventilation, rapidly progressing weakness, inability to walk unaided or significant bulbar weakness).

IVIG  is typically preferred to plasmapheresis in children due to its better safety record and ease of administration

Plasmapheresis can be useful in bigger children where technically it is more feasible to perform. However, there are no reliable studies to suggest one has better efficacy than the other in children.

 

During her admission, Amy has a Gadolinium-enhanced MRI of the spine and nerve conduction studies which are consistent with the acute inflammatory demyelinating polyradiculopathy (ADIP) subtype of GBS. She is given IVIG. She does not develop any respiratory complications. On discharge after three weeks, her weakness is greatly improved and completely resolves over the next two months.

 

Bottom line

  • Clinical examination is key – do not forget to examine reflexes!
  • Always ask about recent viral illnesses.
  • GBS is the most common cause of acute flaccid paralysis in children and 10-20% will require mechanical ventilation.

 

Selected references

Bloch SA, Akhavan M, Avarello J. Weakness and the Inability to Ambulate in a 14-Month-Old Female: A Case Report and Concise Review of Guillain-Barre Syndrome. Case Rep Emerg Med [Internet]. 2013 [cited 2020 Apr 11];2013. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3572648/

 Yuki N, Hartung H-P. Guillain–Barré Syndrome. New England Journal of Medicine [Internet]. 2012 Jun 14 [cited 2020 Apr 5];366(24):2294–304. Available from: https://doi.org/10.1056/NEJMra1114525

Rudant J, Dupont A, Mikaeloff Y, Bolgert F, Coste J, Weill A. Surgery and risk of Guillain-Barré syndrome: A French nationwide epidemiologic study. Neurology. 2018 25;91(13):e1220–7.

Hicks CW, Kay B, Worley SE, Moodley M. A clinical picture of Guillain-Barré syndrome in children in the United States. J Child Neurol. 2010 Dec;25(12):1504–10.

Dimachkie MM, Barohn RJ. Guillain-Barré Syndrome and Variants. Neurol Clin [Internet]. 2013 May [cited 2020 Apr 5];31(2):491–510. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3939842/

Willison HJ, Jacobs BC, van Doorn PA. Guillain-Barré syndrome. The Lancet [Internet]. 2016 Aug 13 [cited 2020 Apr 5];388(10045):717–27. Available from: https://www.sciencedirect.com/science/article/pii/S0140673616003391

Ryan MM. Pediatric Guillain-Barré syndrome. Curr Opin Pediatr. 2013 Dec;25(6):689–93.

Hughes RAC, Wijdicks EFM, Barohn R, Benson E, Cornblath DR, Hahn AF, et al. Practice parameter: Immunotherapy for Guillain–Barré syndrome. Neurology. 2003 Sep 23;61(6):736.

Managing wounds

Cite this article as:
Orla Kelly. Managing wounds, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23609

Wounds are a common presenting complaint to a Paediatric Emergency Department. Children will be children, and slips, trips and falls resulting in minor injuries are all part of growing up. Most wounds are small and can be easily (a relative term!) dealt with in the ED. This prevents the need for referral to speciality care, reduces the time spent in hospital for patients and parents, and provides the satisfaction of a job well done for the ED doc!

Managing expectations

As with any presentation to a healthcare professional, it is important to explore and address patients’ and parents’ concerns and expectations. With wounds, scarring is often a major concern. There are some important points to consider when managing these expectations:

All wounds scar

Scarring is part of the natural healing process of the skin. All full-thickness injuries to the skin will result in scar tissue formation. Multiple factors contribute to the scar that will eventually form – the nature of the injury, the location of the wound, the direction of the wound, some patient-specific factors, the degree tension on closure and lastly, closure technique chosen.

Everyone scars differently

There is no way to tell how each wound will heal. Hypertrophic scars and keloid scarring are patient-specific and often not foreseeable. These can be managed at a later stage by specialist teams. Other patients are at risk of poor healing – smokers (hopefully not too common in a paeds ED), diabetics, long term steroid users and those with other chronic diseases.

The most important part of wound management isn’t the closure but the cleaning

Infected wounds will heal badly (if at all) and can affect the underlying structures. Patients and parents need to aware to look carefully for any redness or exudate that might indicate infection and to seek medical attention appropriately.

Different wounds require different closures

Some parents will be set on the idea that stitches are superior – this is not always the case as we’ll discuss later.

Wounds take longer than a few days to heal

Wounds heal in three phases – inflammatory (day 1-3), proliferative (day 4-21) and remodelling (day 21 – 1 year). Scars can, therefore, take up to 12 months before they reach their final appearance. Because of this patients and parents need to know that the initial appearance is not the final outcome.

That said, measures can be implemented to reduce scarring

For instance, I recommend Steristrip support for a week, and then pinpoint massage with petroleum jelly or other oil-based products for a month to six weeks to provide a moist wound bed and reduce visible scarring. Sun protection is also important – the wound should not be exposed to the sun for at least three weeks, and sun cream used for more than a year on that area.

Scar revision is possible at a later stage

If after initial closure and sufficient healing time has passed, and a scar still remains that is distressing to the patient, referral for scar revision is possible.

Managing clinicians

It can be often tempting to be distracted by a nasty wound. No doubt the patient will be. But it is important to see the bigger picture and not to miss any important steps in management. Having a structure to work through is always something I find helpful, and the following questions will make sure your patient is treated safely and comprehensively.

  1. Is there any other associated injury?

Always think of the ABCs and make sure any haemorrhage has been controlled. Has the patient received a head injury, or has another body part been injured?

  1. How has it been caused?

The history of the injury will lead you to suspect any further damage or special considerations for management. For instance, was the wound caused by a sharp instrument or blunt trauma? Did it happen in a particularly contaminated area (e.g. a farmyard accident) that would prompt the need for surgical washout and antibiotic coverage. If describing wounds in medical notes be careful of nomenclature – if in doubt use ‘wound’. An abrasion is a wound caused by friction (a graze, or road rash for instance). These can be tricky to clean, but it’s important to remove any debris, otherwise a tattoo type scar can remain. A laceration is caused by a shearing force; these are more difficult to repair as there has been surrounding tissue damage. An incisional wound is caused by a sharp object, often more straightforward to repair. A puncture wound is one where the skin has been breached and is deeper than it is wide. Beware of these wounds – they are the icebergs of the wound world – who knows what is going on beneath the surface?

  1. Is there a foreign body present?

Puncture wounds, in particular, carry a high risk of foreign bodies, and therefore of infection and wound breakdown. If a foreign body is suspected, an x-ray is reasonable as it will pick up metal and most glass, although it won’t demonstrate wood, plastic and clothing. For cases where suspicion is high, ultrasound can be used to pinpoint the material. Often, in this case, speciality services need to be contacted.

  1. How deep is the wound and might other structures be involved?

The location of the wound and a good knowledge of anatomy is particularly important when it comes to this question. Wounds on the hands and arms, for instance, carry a high risk of underlying tendon and nerve damage. Always make sure to test and document a neurovascular examination distal to the wound.

  1. Is it safe to close the wound immediately?

If the wound isn’t too old (opinions differ on this, but usually >8hrs) or contaminated then healing by secondary intention is usually preferred in order to avoid sealing in infection.

  1. How should the wound be best closed?

Factors which help in making this decision include the size of the wound, the location and the degree of tension it is under.

  1. What dressing should be used?

Usually, a non-adherent dressing for abrasions will facilitate healing as well as less painful dressing changes. Wounds that have been sutured can be covered with a simple bandage. Other wounds on fingers or places likely to get wet (or drooly!) may require a waterproof dressing.

  1. Does the area need immobilisation?

If the wound is over a joint or subject to movement, it is good practice to immobilise the joint in order to allow healing. Beware wounds overlying joints and ensure that there is no communication with deeper structures.

  1. Are antibiotics indicated?

There is no evidence for ‘prophylactic’ antibiotics in simple wounds. However, those that are heavily contaminated, or involve joints or underlying structures/fractures will often require specific antimicrobial cover (and surgical washout). Consult with local speciality teams for their preferences.

  1. Is the child tetanus immune?

Always important to check the immunisation status of any child presenting to a healthcare professional. Consult national guidelines as to the recommendations for tetanus prone wounds and indications for booster shots and immunoglobulin.

First – let us remind ourselves of the structure of the skin. It is composed of the epidermis and dermis, and underlying subcutaneous layers.

The structure of skin

Wounds to the epidermis are very superficial; the dermis and epidermis are tightly adherent to each other. Wounds to epidermis need nothing more than a wash and a non-adhesive dressing (a sticking plaster or Band-Aid). Do not be tempted to glue or suture these as they will worsen outcomes.

Wounds that extend through to dermis or subcutaneous layers must be treated with more care. Of course, the age of the patient will determine the approach, but the management remains the same. The following are some techniques to allow us to manage our patients, before the wounds.

Managing patients

If your department is lucky enough to have a play specialist – use them. They can magically turn a difficult situation into a calm and even fun event. Using distraction techniques (I personally turn to the name of the blog for my distraction of choice) a child can be calmed and the wound can either be managed immediately, or anaesthetised.

LAT gel (lidocaine adrenaline and tetracaine) is magical stuff. A mixture of local anaesthetic and adrenaline, it takes about 20-30 minutes to be effective, and it helpfully blanches affected skin (due to the adrenaline) to show you it’s ready. Generally not suitable for under 1s (an infant presenting with a wound that requires suturing should prompt immediate senior review), the doses are 0.5ml/1cm of wound, with a max dose of 2ml in 1-3 year olds and max 3ml in >3 years. It shouldn’t be used on mucous membranes or eyes due to absorption or on extremes of digits, nose, genitalia or ears due to the vasoconstriction effect of the adrenaline, or wounds greater than 8 hours old (as these are likely to need formal washout). LAT gel can also be used to sufficiently numb an area enough for local anaesthetic injection if further anaesthesia is required. Remember the full dose of lidocaine shouldn’t exceed 5mg/kg. Inject local anaesthetic SLOWLY using an orange needle – local anaesthetic is painful when injected, so infiltrate slowly to negate this, and use a small gauge needle.

The other option is procedural sedation. This is department-specific and dependent on the availability of senior clinicians and departmental equipment/space. It can allow for a more thorough washout and definitive closure of wounds without another trip to the hospital.

If there is an obvious underlying fracture or structural (ie nerve or tendon) defect, then the patient requires a referral for speciality treatment, and is not suitable for ED closure, so I don’t see any benefit in further possibly distressing a child by poking and prodding – one such session is enough!

Managing wounds

Once the patient is suitably distracted/analgesed/sedated, it’s time for the easy part. Wounds must be cleaned thoroughly, and underlying structures assessed. If there is any risk of underlying fracture, an x-ray is mandatory – a missed open fracture is unacceptable. Normal saline is perfectly fine for wound washout. All large/visible debris should be removed, and then the wound thoroughly irrigated. I find an 18G cannula (with the sharp bit removed) attached to the end of a 20ml syringe for small wounds works well as it gives good pressure effect. For larger wounds, a 50ml syringe on its own can be used. There is no consensus around the amount of fluid needed for a washout. It is often clinician and wound dependent. If in doubt, keep washing it out!

Now for the closure. Depth, length, tension and location are the predominant features that guide the decision for closure materials and techniques. It is important to remember that the goals of wound closure are to eliminate dead space, avoid dehiscence by using appropriate materials and technique, and approximate wound edges without tension.

Paper stitches

Paper stitches, butterfly stitches, or Steristrips©, are fantastic when used for wounds with low tension (i.e. the wound edges are easily apposable). They come in a range of sizes to fit different wounds and locations. Make sure to cut them to size; if they are too long the edges can peel away and little fingers can be tempted to peel them off. Place them perpendicular to the wound, sticking down one side first, then gently pinch the wound edges together, and secure the other side down. Ensure the wound edges are everted (the pinching helps). Leave approximately 3mm in between each strip. A parallel strip can be added to the ends of the strips at either side of the wound (not directly over it) to help prevent them peeling away. Cover with a regular dressing. I advise using tincture of Benzoin as an adjunct – it increases the adherence of the Steristrips© (and smells nice). If the area is likely to get wet (i.e. chin), a personal trick is covering the closed wound with a DuoDERM©, or equivalent dressing, as it will help it stay protected. Give the usual infection safety net advice to parents. I generally advise them to leave the Steristrips© in situ until they themselves fall off naturally (usually that gives plenty of time for the wound to heal). Steristrips© aren’t suitable for wounds that are under tension or likely to be subject to movement such as over joints.

Glue

Tissue adhesive has been covered in a separate blog post which can be found here

Sutures

For most wounds being repaired in the ED, simple interrupted sutures are appropriate.

Simple interrupted dermal sutures can be absorbable (eg Vicryl Rapide©) or non-absorbable (eg nylon, Prolene©, Seralon©).

Absorbable sutures are useful under casts, where it’s not possible to remove them after a required time, or for wounds in young children where suture removal could cause distress and the wound is not in an area of cosmetic concern (e.g. scalp).

For facial wounds, non-absorbable sutures should be used, as absorbable sutures may not disintegrate prior to the epithelisation of the suture, leaving the stereotypical ‘dots’ either side of the wound site. Use the smallest suture possible. Holding the needle 2/3 along the curve with the needle-holder, always position the tip of the needle at a 90-degree angle to the skin, and using a supination movement rather than pushing or dragging the needle through the tissue, make a corresponding incision on the other side of the wound and tie the knot. Tying the knot parallel rather than perpendicular to the wound can result in better eversion and therefore better cosmetic outcome. Remember – approximate, don’t strangulate. The base of the suture should be wider than the top in cross-section – this gives strength to the wound and ensures no deep cavities are left. A useful trick in ensuring this shape to the stitch is to gently evert the second side of the wound as you’re passing the needle from deep to superficial. Sutures should be removed between day 3-5 on the face, and around day 7 on the rest of the body.

Geeky Medics have a lovely video on simple interrupted sutures.

Deep dermal sutures are sometimes required if the wound is under tension. In this case, a reverse suture from inside-out for the initial stitch, with a corresponding outside-in stitch on the far side allows you to bury the knot. An absorbable suture such as Vicryl© or Monocryl© is great for this. As the knot is being buried, only three throws should be used. With deep dermal sutures, the superficial dermal sutures should not be under tension and just provide a means to evert the wound edges. Deep sutures are at more risk of infection as you are leaving foreign material in the wound. For simple facial lacerations in children, they are often not necessary. The Children’s Hospital of Philadelphia has a great video on deep dermal sutures.

Special considerations

Bites: Bite wounds are prone to infection and therefore require antibiotic cover. They usually should be left to heal by secondary intention, as closure of these wounds can result in deep-seated infections. If they are deep to subcutaneous tissues, washout in theatre is likely more suitable than in the ED.

Large area superficial abrasion (eg road rash): These are difficult to treat and clean. The use of a porous sponge and surfactant cleaner is useful here. If it is extensive and the patient uncooperative, often sedation or GA is most appropriate.

Delayed presentation: Wounds that present after 24 hours are unsuitable for primary closure due to the high risk of infection. Thorough cleaning with regular dressings and close follow up with possible grafting or scar revision is often necessary.

Selected references

Grabb and Smith’s Plastic Surgery 7th Edition, Editor in chief Charles H Thorne, Lippincott Williams And Wilkins Philadelphia 2014

Commander SJ, Chamata E, Cox J, Dickey RM, Lee EI. Update on Postsurgical Scar Management. Semin Plast Surg. 2016;30(3):122–128. doi:10.1055/s-0036-1584824

Paediatric Emergencies Beattie, Hendry, Duguid, 1997, Mosby-Wolfe Barcelona

Ghafouri HB, Bagheri-Behzad B, Yasinzadeh MR, Modirian E, Divsalar D, Farahmand S. Prophylactic Antibiotic Therapy in Contaminated Traumatic Wounds: Two Days versus Five Days Treatment. Bioimpacts. 2012;2(1):33–37. doi:10.5681/bi.2012.004

Kanegaye, J. A Rational Approach To The Outpatient Management of Lacerations In The Pediatric Patient. Current Problems In Paediatrics. 1998: 28(7):205-34.

Tissue Adhesive

Cite this article as:
Andrew Tagg. Tissue Adhesive, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.17898

Jason and his little brother, Freddie, were chasing each other and running around the house when little Fred slipped and went flying into the coffee table. There were screams, there were tears and there was blood. As you peel away the Paw Patrol plaster from his forehead you see a 2cm vertical laceration. An anxious parent hovers nearby, almost afraid to look. “Will he need stitches, doctor?”

The smile behind the mask

Cite this article as:
Dani Hall. The smile behind the mask, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.25025

Earlier this week I was in an ED but, instead of being in my usual role as a doctor, I was there as a relative. It was scary. I was worried and everything was strange. People walked down the corridors in single file, wearing masks. The public areas were silent. The coffee shop was deserted. I didn’t really know any of the staff but I was so touched by the kindness shown by people I’d only ever known on Twitter. As I spoke to a consultant dressed in full PPE, it really struck me how much harder we have to work to convey tenderness and warmth behind the mask, how difficult it is to show our patients we’re there for them as humans as well as diagnosticians, how terrifying it must be for our younger patients, the children at the heart of COVID.

While chatting with the DFTB team about what we can do to make our own places of work less scary during COVID, Damian reminded me about this video by EM3. Imagine the same video with staff in full PPE. Imagine what it’s like to be in your COVID ED from the perspective of a frightened child.

 

Our children are struggling with isolation and suffering with worry, anxiety and fear. And while speaking to the ED consultant, feeling those emotions myself, I resolved to go on a hunt for ways we can unmask our smiles.

 

Ask how things are going

We can make an extra effort to ask how our patients and their parents are feeling. Daniel Summers has written this moving article which is touching in its exploration of empathy.

“To my usual list of questions about diet and exercise and sleep and such, I have started asking parents “so how are you doing with all of this?” How is it with your kid at home with you all day, every day? What are their school’s expectations? How are things with the work you have to do yourself? How are you coping?” Daniel Summers.

 

Show who are you are beneath the mask

Writing our name on our PPE replaces our hidden lanyards (#hellomynameis has never been more important) but our faces, which usually convey so much emotion, tenderness, and warmth, still remain hidden. I love the idea of a photo to show the person behind the PPE.

Maybe a laminate a few and disinfect them between patients or, instead, use a paper print out or a sticker, and get a new one per patient.

 

Pimp your PPE

Conversations on Twitter have highlighted some great ways we can pimp our PPE (what a great hashtag that would make). So, although we probably shouldn’t be drawing on our masks as it might impact on their effectiveness, that doesn’t stop us making our visors more beautiful.

If you have the skills then drawing on aprons is another way to pimp your PPE, demonstrated so brilliantly on the Portsmouth PED catwalk.

An alternative is to whip out those accessories to wear under the PPE.

 

Make kids giggle

We’re used to hunting for dinosaurs in ears and using our magic hands to feel for brekkie in bellies, so why not use some silliness to break the ice.

Be a superhero…

…play a game…

…or just be funny.

 

We are advocates of smiling eyes and a playful disposition, open and positive body language and tone of voice.” Sian Spencer-Little, explaining the philosophy of the play team at GOSH.

 

Use communication cards

Inspired by an adult patient who described feeling terrified because he couldn’t understand what his clinicians were saying through their PPE, an anaesthetist in the NHS has developed CardMedic.com, a collection of flashcards used to communicate with patients. These could be adapted for older children, with language pitched age appropriately.

And for younger children? While chatting about how we can overcome the PPE barrier with children, Sian told me she’d been thinking about using wipeable PECS cards (from the picture exchange communication system), adding images of masks, visors and other images to explain our PPE.

 

Add a bit of colouring

These lovely colouring sheets have been created by Stephen Browne, an Irish designer, and Emma Fratangelo, a play specialist in Children’s Health Ireland. Click on the image to download the pdf for your own hospital.

 

Put up some posters

And if your department is looking for some posters or information to give to children, these resources are lovely for children both young and old.

“We might look a bit different than usual. It’s ok to laugh!”, Katie Chappell.

 

Thanks to Amanda Stock and the team at RCH for this great video that takes a little of the mystery out of PPE.

And so, while COVID reigns we don’t have to be hidden behind our PPE. We can show our smiles behind our masks.

“What I miss most in this current climate is normal human contact, the essence of our everyday and medical world – the unmasked smile, the warmth of a handshake, the reassurance of a touch on the shoulder, the hug from a patient when a particular connection has been made… But, I also know that the common bonds that bring us together will be strengthened, not weakened by this experience.” Gaye Cunnane, the Royal College of Physicians of Ireland.

 

Resources

Monkey Wellbeing resources can be found at https://www.monkeywellbeing.com/

Katie Chappell’s cartoon is available in English and Welsh at https://www.katiechappell.com

The child with a limp

Cite this article as:
Andrew Tagg. The child with a limp, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23509

This post is based on the talk Andrew Tagg was invited to give at BadEMFest20 in Capetown. Unfortunately, world events made that a little challenging.

Humans evolved from Homo erectus to Homo sapiens around 500,000 years ago. Fossils dug up from by the Leakeys in Olduvai Gorge, Tanzania, revealed how we moved from shuffling knucklewalkers to the upright hominids we recognize today. Walking on two legs allowed us the freedom to use our hands – to communicate, to use tools, and to keep ourselves safe.

 

How do we walk?

The normal human gait is comprised of three distinct phases:

  • The contact phase – from heel strike to flat foot
  • The stance phase – from flat foot to heel off the ground
  • The swing phase – the propulsion phase as weight transfers from the toes

The swing phase normally comprises 40% of the gait cycle.

 

 

Like Sherlock Holmes or his progenitor, Joseph Bell, if you watch your patient walk you can get a lot of clues as to the potential underlying pathology before you even exchange a word with them or their parents.

Antalgic gait

This hobbling gait has a normal contact phase and normal propulsion with a decreased stance phase. In essence, the patient is trying to decrease the amount of time spent bearing weight through the hip joint itself.

Trendelenburg gait

In this gait disturbance, the hip muscles are too weak and so the unaffected side drops towards the floor. It suggests a biomechanical issue such as ass avascular necrosis, or a slipped capital femoral epiphysis.

Circumduction gait

The patient swings their leg out and around to clear the floor. This is often due to a leg-length discrepancy in the delayed diagnosis of developmental dysplasia of the hip (DDH).

Equinus gait

Toe walking, though normal up to the age of three may suggest that the child is unwilling or uncomfortable engaging their gastrocnemius muscles in walking. This can occur in many conditions.

 

The rate of presentation to the emergency department with an atraumatic limp is approximately 1.4 per 1000 in children under the age of 14. It occurs more often in boys than in girls (1.7:1) and the median age is 4.4 years. When we consider the potential causes the list is massive. In this post, we are going to concentrate on both the more common conditions and those diagnoses that we really shouldn’t miss. Whilst any part of the limb might be the cause (from the toes to the hip) this post is going to focus on causes centred around the hip joint. They account for about 60% of cases of limp. That doesn’t mean you shouldn’t look in their shoes for pebbles or look at their toes though!

Let’s break it down to some age-specific diagnoses and those that can occur at any age


Late presentation of developmental dysplasia of the hip (DDH)

It is just possible that routine screening with Ortolani’s and Barlows test might have missed a case of hip dysplasia. The limb resultant limb shortening can be hard to detect if it is bilateral but this is one time to get out the tape measure and look for a leg length discrepancy as you measure from anterior superior iliac spine (ASIS) to medial malleolus.

If you don’t have a tape measure to hand then look for a positive Galeazzi sign, suggesting a shorter hip segment on the affected side.

Original by Walt Shumway

 

Transient synovitis

This diagnosis accounts for the majority of cases of atraumatic limp and may follow an upper respiratory tract infection though the evidence for causation is poor. It is most common in young boys, aged 4 to 8 years of age and is self-limiting in nature. It’s a diagnosis of exclusion rather than anything else made easier by the well-appearing, afebrile child. It should respond to simple NSAIDs though is recurrent in 20% of cases.

Dr. Sathya Subramaniam, Pediatric EM Fellow – Kings County/SUNY Downstate and The POCUS Atlas

According to Viera and Levy, bedside sonography has a sensitivity of 90% and specificity of 100% to detect an effusion. Unfortunately, it doesn’t help with determining the cause.

Occult trauma

It’s beyond the scope of this post to talk about NAI and long bone injuries in children (especially as Nikki Abela did such a great job at DFTB18) so instead, it’s worth thinking about toddlers’ fractures. These occur due to torsional force on the tibia, accompanied by a fall, and may only be picked up as tenderness over the distal third of the tibia. That first set of x-rays performed in the emergency room may not show any obvious pathology with signs only becoming obvious after a couple of weeks. This is one of those occasions where ultrasound may be much more helpful though if clinical suspicion remains it should be treated with immobilization and close follow-up. Repeat imaging may then show the beginnings of some callus formation or a radionuclide bone scan may be needed. If they are not toddling and waddling it is not going to be a toddler’s fracture.

 

Case courtesy of Dr. Jeremy Jones, Radiopaedia.org. From the case rID: 9317

Neuromuscular

Although unlikely to present as an isolated limp, cerebrovascular events may present as hemiparesis; It’s beyond the scope of this post to go into them in more detail. Watch this space.

 

Perthes disease

This is idiopathic avascular necrosis of the growing femoral head and typically presents in boys at the younger end of the scale (4 to 8 years old). Because of this, these children are often shorter than their peers and there is a possible association with hyperactivity. The classical findings on a plain AP x-ray of the pelvis include sclerosis leading to destruction and the eventual collapse and flattening of the femoral head.  As this is a biomechanical problem, they might present with a slow onset antalgic gait with pain on internal rotation and ABduction. Around 20% of cases are bilateral.

Case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 7980

 

Both MRI and bone scan are equally sensitive if the plain films are equivocal. Treatment may be surgical or conservative depending on the degree of bone destruction and the age of the child. Left unchecked neovascularization occurs with the destruction of the femoral head.

Though first described in 1897, it was not until 1910 that it was found to be unrelated to tuberculosis. Arthur Legg, Jacques Calvé and Georg Perthes are guilty of its eponymous name.

Transient synovitis

I think we’ve said enough about transient synovitis already.

Neuromuscular

As well as a stroke a limp might be the initial feature of an ascending paralysis in Guillain-Barré. We’ll talk about that and ADEM another time.

 

Slipped Capital Femoral Epiphysis

A slipped capital femoral epiphysis or slipped upper femoral epiphysis is more common on older, overweight boys, over the age of 10 years of age. There is often a structural weakness of the physis itself so it is more common in cases of endocrine dysregulation (such as hypothyroidism) and metabolic conditions (such as renal osteodystrophy). The proximal epiphysis displaces anteriorly and laterally relative the metaphysis. Involvement of the medial obturator nerve may mean that they present as knee pain rather than hip pain. Early fixation and we mean in less than 24 hours in unstable cases, can ward off the threat of life-long pain and deformity. Plain AP films may not be enough in the case of subtle slippage. So if you are suspicious then you should go ahead and order a lateral film as well.  A lot of other hip pathology is made easier to spot in a frog-leg lateral. Don’t do this if you are suspicious of a SCFE, you might make things much, much worse.

Look for Klein’s line. A line along the superior aspect of the femoral neck should intercept with the epiphysis. Imagine it as an ice cream slipping off the cone on a hot summer day.

Adapted from case courtesy of Assoc Prof Frank Gaillard, Radiopaedia.org. From the case rID: 2715

Case courtesy of Dr. Hani Salam, Radiopaedia.org. From the case rID: 9298

 

 

Some things need to be in our differential no matter the age of the child.

Septic arthritis

The hip is the most commonly infected joint with the haemategenous spread of organisms grown dependent on the local flora. Young children (under the age of 2), those who are immunosuppressed or asplenic are at higher risk. In Australia, for instance, the commonest organisms grown are Staphylococcus aureus and Group B Streptococcus (especially now that Haemophilus influenzae b infections have been almost wiped out by immunization). In the youngest, patients consider the weirder organisms like Kingella kingae and Salmonella (in patients with sickle cell disease).

The juvenile physis does not prevent the spread from a remote source from entering the epiphysis and so haematogenous spread (rather than direct local invasion) is often the culprit. The hip is classically held in a position of external rotation, ABduction and, flexion, perhaps in an effort to maximize the joint space and minimize the pain.

It would be great if there was a way we could differentiate the serious diagnosis of septic arthritis from something less serious, such as transient synovitis. Step forward Meninder Kocher et al. and their seminal paper.

Kocher MS, Zurakowski D, Kasser JR. Differentiating between septic arthritis and transient synovitis of the hip in children: an evidence-based clinical prediction algorithm. JBJS. 1999 Dec 1;81(12):1662-70.

They looked at 17 years of data for patients that presented to a single tertiary hospital with an acutely irritable hip. This amounted to 282 cases in all of which only 168 had their hip joint aspirated.  Of this 168,  only 26 had true septic arthritis as confirmed by a positive culture of joint aspirate or 50,000 WCC in the aspirate with a positive culture, 9 had a positive joint culture and negative blood cultures and 3 had only positive blood cultures.  By performing a multivariate analysis they then looked for key indicators that differentiated cases of septic arthritis from the more benign irritable hip. Four key factors cropped up. They were a history of fever, inability to bear weight, a WBC greater than 12 x 109/l and an ESR ≥ 40mm/hr. If you had none of these then the probability of having septic arthritis is 0.1%. But if you have all four it jumps to 99.8%.

Of course, this is all the primary literature that most people read but when Kocher tried to validate the study having all four markers gave the chance of having septic arthritis as 93% and when Luhmann et al. tried to externally validate the criteria it dropped to 59%. Caird et al. must have realized that not many of us use ESR any more and so appended the more common C-reactive protein (CRP). Having all 5 gave a 97.5% positive predictive value though there were only 14 cases of transient synovitis, and 5 of septic arthritis.

 


 

Osteomyelitis

An indolent course and a non-specific physical examination make this a difficult diagnosis to pick up at first glance. Around 1.5-2% of all children presenting with an atraumatic limp will have osteomyelitis.  Plain films may be unremarkable early in the course of the illness and only show periosteal changes after a week to 10 days. An MRI scan is more sensitive and if the diagnosis is still a challenge then radionuclide scanning might pinpoint the infection. The hip is one of the more common joints affected (25%) followed by the tibia/fibula (25%) then the humerus (13%). Osteomyelitis and septic arthritis can coexist as infection from the bone spreads to the joint capsule.

 

One case series suggests that 40% of cases are due to transient synovitis, chronic muscle sprain or trauma accounted for 16% and no diagnosis was made in 30%. All those diagnoses we have to learn for exams are much less common (Perthes’ disease 2%, osteomyelitis 1.5%, toddlers’ fractures 1%, and SCFE 1%). What has not been mentioned, as the incidence is incredibly low is the thing that many parents worry about – cancer.

 

Malignancy

Whilst parents may not have heard of a slipped capital femoral epiphysis or Kocher’s criteria but they have heard of cancer and so we need to address it. Primary benign tumours (unicameral bone cysts, for example, as well as malignant ones can present as bony hip pain.  Hip pain can also be a presenting feature in haematological malignancies such as acute lymphoblastic leukaemia. The most common malignant bone tumours in infants are osteogenic sarcoma and Ewing’s sarcoma. Both of these are most common in the second decade of life.

Persistent pain, coupled with constitutional symptoms such as night sweats, weight loss and night pain are highly suspicious and should prompt imaging and blood tests.

 

 

 

Selected references

Please, Just STOP LIMPING from Tim Horeczko and the PEM Playbook

Septic arthritis from PEM Morsels

 

Adamson J, Waterfield T. Fifteen-minute consultation: The limping child. Archives of Disease in Childhood-Education and Practice. 2019 Jun 29:edpract-2018.

Caird MS, Flynn JM, Leung YL, Millman JE, Joann GD, Dormans JP. Factors distinguishing septic arthritis from transient synovitis of the hip in children: a prospective study. JBJS. 2006 Jun 1;88(6):1251-7.

Fischer SU, Beattie TF. The limping child: epidemiology, assessment and outcome. The Journal of bone and joint surgery. British volume. 1999 Nov;81(6):1029-34.

Flynn JM, Widmann RF. The limping child: evaluation and diagnosis. JAAOS-Journal of the American Academy of Orthopaedic Surgeons. 2001 Mar 1;9(2):89-98.

Herman MJ, Martinek M. The limping child. Pediatrics in review. 2015 May;36(5):184-95.

Hill D, Whiteside J. Limp in children: Differentiating benign from dire causes. Journal of Family Practice. 2011 Apr 1;60(4):193.

Hussain M, Gholipour B, Owen N. A pictorial review of the radiological presentations of the child presenting with an acute limp in the emergency department. Clinical Radiology. 2019 Oct 1;74:e14.

Kocher MS et al. 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.

Leet AI, Skaggs DL. Evaluation of the acutely limping child. American Family Physician. 2000 Feb 15;61(4):1011-8.

Lewis D, Logan P. Sonographic diagnosis of toddler’s fracture in the emergency department. Journal of Clinical Ultrasound. 2006 May;34(4):190-4.

Long B, Koyfman A, Gottlieb M. Evaluation and Management of Septic Arthritis and its Mimics in the Emergency Department. Western Journal of Emergency Medicine. 2019 Mar;20(2):331.

McCarville MB. The child with bone pain: malignancies and mimickers. Cancer Imaging. 2009;9(Special issue A):S115.

Mooney III JF, Murphy RF. Septic arthritis of the pediatric hip: update on diagnosis and treatment. Current opinion in pediatrics. 2019 Feb 1;31(1):79-85.

Perry DC, Bruce C. Evaluating the child who presents with an acute limp. BMJ. 2010 Aug 20;341:c4250.

Ryan DD. Differentiating Transient Synovitis of the Hip from More Urgent Conditions. Pediatric annals. 2016 Jun 15;45(6):e209-13.

Sawyer JR, Kapoor M. The limping child: a systematic approach to diagnosis. American family physician. 2009 Feb 1;79(3):215.

Singhal R, Perry DC, Khan FN, Cohen D, Stevenson HL, James LA, Sampath JS, Bruce CE. The use of CRP within a clinical prediction algorithm for the differentiation of septic arthritis and transient synovitis in children. The Journal of bone and joint surgery. British volume. 2011 Nov;93(11):1556-61.

Vieira RL, Levy JA. Bedside ultrasonography to identify hip effusions in pediatric patients. Ann Emerg Med. 2010;55(3) :284-9

Wainwright, AM; Catterall, A (2010). “Chapter 27: Legg–Calvé–Perthes disease: Its name”. In Benson, M; Fixsen, J; MacNicol, M; Parsch, K (eds.). Children’s orthopaedics and fractures (3rd ed.). London: Springer. p. 465

Prehospital PEM Pearls

Cite this article as:
Dani Hall. Prehospital PEM Pearls, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24496

This post is dedicated to my prehospital friends and colleagues and is based on a talk I gave for University College Dublin. Stay safe out there.

Once upon a time there was a school called Hogwarts. And in that school were two friends, Ron and Hermione. They went on many adventures and, well, to cut a long story short, Ron and Hermione fell in love and got married. Although they both had good jobs with the Ministry of Magic, with Brexit looming Ron and Hermione decided to leave the UK and return to the country of Ron’s roots. They settled in a small country home on the west coast or Ireland. And it was there that their first baby was born.

Finlay, or Finn for short, is two weeks old and gorgeous, cute and super cuddly. His parents however, have just lived their worst nightmare. Finn was lying on the play mat when he suddenly went grey and ashen. Hermione picked him up but he was floppy and not breathing. She screamed for Ron who came running in and his initial thought was that Finn had died. He called 999 but before he’d ended the call, Finn had started breathing again and he was back to his normal self within 30 seconds. The paramedics arrive and check a blood sugar, which is 5.2, and his observations are normal. They wrap him up in a blanket and move him into the back of the ambulance. There they reflect on a paper they’d read recently on neonatal transport.

Duby et al, 2018. Safety Events in High-Risk Prehospital Neonatal Calls. Prehospital Emergency Care

This paper, published in 2018, looked retrospectively at all “lights and sirens” ambulance transports of neonates 30 days and younger over a four-year period in Oregon, Michigan.

During these four years, 26 neonates were blue lighted to hospital. Safety events, such as medication errors, airway management difficulties, resuscitation errors and clinical assessment and decision errors occurred in 19 babies. That’s almost three-quarters of all the transfers. Serious safety events, potentially causing permanent injury or harm, occurred in 10 babies, that’s more than a third of all neonatal blue light transfers. Specific examples included tenfold adrenaline dosing errors, failure to obtain IV or IO access and failure to adequately ventilate with bag-valve-mask devices.

This is pretty huge. Why were safety errors so common? The authors propose three reasons:

Firstly, very young babies blue-lighted by ambulance are more likely to be very sick, with life-threatening emergencies.

Secondly, neonates are the most dissimilar to adults. This is especially true for newborn babies, whose physiology is so significantly different from older children and adults because of the physiological transitions as they adapt to a life outside the uterus. The newborn life support algorithm is adapted specifically because of this, with 3 breaths to every chest compression instead of the 15 to 2 for children.

And thirdly, high-risk neonatal transfers are very infrequent. Mix low frequency yet high acuity illnesses with different physiologies, different disease processes, and dosing difficulties and you can see why the chance for error is high.

So, what can you do to mitigate these risks?

Practice, practice, and well… practice. For any presentation that’s low-frequency but high-acuity, falling back on a well-rehearsed algorithm helps with cognitive offload, minimizing the potential for error. Practicing neonatal resuscitation until you can do it with your eyes closed will help you get into the cognitive groove when it happens for real. Running skills and drills, like bagging a neonatal mannequin or putting IO needles into teeny tiny simulated legs (sticks are perfect) will help get over the adrenaline-induced block in the real thing. And practicing neonatal drug calculations, using apps to calculate those tiny medication doses, and then drawing up the neonatal sized drug volumes will 100% help improve safety.”

So, with that in mind, the paramedics review drug doses and treatment algorithms while transporting Finn to hospital. The journey, thankfully, is uneventful. But, they wonder, what had caused him to go so floppy and grey?

Finn had what we now call a BRUE – a brief, resolved, unexplained event.

Tieder et al, 2016. Brief Resolved Unexplained Events (formerly Apparent Life Threatening Events) and evaluation of lower risk infants. Pediatrics

This paper, published in 2016, provides evidence-based recommendations for low-risk babies who present with a BRUE. The key is in the words BRIEF and UNEXPLAINED. If the episode wasn’t brief (less than a minute) or unexplained then they didn’t have a BRUE. So forget about those babies who’ve had a funny episode whilst being snuffly for a few days (they’ve probably had an airway or respiratory episode) or the babies who went pale and floppy choked during a feed (they probably refluxed) or the babies with a fever (they could be septic).

The term BRUE has now replaced ALTE (previously known as Acute Life-Threatening Events, a pretty unhelpful term because it’s just so vague and so incredibly subjective) and also replaced that golden-oldie term, Near-Miss Sudden Infant Death Syndrome (a highly emotive and immensely unhelpful term) and looks like it has changed practice in at least some institutions.

In ED Finn looks like a healthy baby. He has a bottle of milk and looks like one of the cutest babies there ever was. Because he is so young, he has a set of bloods done, which are normal, and Hermione finally manages to catch a wee sample (after missing one onto the floor), which is also normal, and he is admitted for overnight observation. Finn remains well on the ward and is discharged the next morning.

6 months pass. Finn is doing brilliantly. But one morning he wakes up with a cough and two days later starts breathing really fast. He can’t manage a bottle and his little tummy is sucking in and out with every breath. In a panic Ron dials for an ambulance and soon help is at hand. The paramedics take one look at Finn and take a collective deep breath. He’s working pretty hard. They get him hooked up to the monitor: sats 89%, HR 190, RR 56. A quick listen to Finn’s chest reveals widespread wheeze and crackles. Wheeze. Right. Out comes the salbutamol. 2.5mg as per the clinical practice guideline.

Wait. Hold that thought. What are we treating here? Finn is wheezy. So he has bronchospasm, right? Wrong. Let’s stop for a second and think about wheeze in infants.

Wheeze in infants

Wheeze is a noise we hear when air passages are obstructed. We classically think of wheeze as being due to bronchospasm. And salbutamol relieves bronchospasm. But, and this is a big but for paediatrics, infants don’t get bronchospasm when they have a virus. So salbutamol doesn’t work.

If you think of the respiratory system as being an upside-down tree, the trunk is the trachea, the first two branches are the right and left main bronchi, the next branches are the lobar and then segmental branches, and finally, you get to the twigs. The bronchioles. The classic wheeze that we see in children and adults is due to bronchospasm – that’s constriction of the bronchi. Beta-2 receptors on the smooth muscle cells of the bronchi respond to Salbutamol – give enough bronchodilator and the airways will relax. Goodbye wheeze. Children from about the age of 12 months can get something called “viral-induced wheeze” – bronchospasm triggered by a virus, much like a viral exacerbation of asthma. Because this is bronchospasm, salbutamol works.

However, babies don’t get viral-induced wheeze. They get bronchiolitis. When the teeny tiny twiggy bronchioles become inflamed, this is bronchiolitis – itis (inflammation) of the bronchioles. Bronchiolitis affects infants from birth until somewhere between their first and second birthdays and is the most common lower respiratory tract disorder in infants aged less than 12 months. Like viral-induced wheeze it’s also due to a virus (classically RSV but many other viruses can cause it too). The baby starts with a cough and a snuffly nose. The bronchioles gradually become inflamed and fill up with secretions. And these secretions obstruct the airway and voila – you hear wheeze and crackles when you listen to the lungs.

There’s no bronchospasm anywhere. So bronchodilators like salbutamol just won’t work.

And if you do give salbutamol to a little baby with bronchiolitis? Well… Salbutamol is a beta-2 agonist – it’s the beta-2 receptors on the bronchi that it acts on in viral-induced wheeze and asthma. But it also has a weak beta-1 effect causing tachycardia, dizziness, and nausea. So, now you have a baby with respiratory distress that’s not improved and now they’re tachycardic on top. Not ideal.

Generally, infants under 12 months have bronchiolitis, toddlers over 2 years have viral-induced wheeze, and the 1-2-year-olds may have either.

Of course nothing magic happens on a baby’s 1st birthday (even if you are a baby born to a wizard and witch) so there may be the odd 10 or 11 months old with viral-induced wheeze rather than bronchiolitis.

What can the paramedics do for Finn? He’s working pretty hard with his breathing. At 6 months old this is almost certainly bronchiolitis. And they now know salbutamol will only cause harm. Surely there’s something that can be done? 

OBrien et al on behalf of the Paediatric Research in Emergency Departments International Collaborative Network, 2018. Australasian Bronchiolitis Guideline. Journal of Paediatrics and Child Health

In 2018, the Australasian paediatric research network, PREDICT, published a systematic review of the literature on bronchiolitis and used it to produce the Australasian bronchiolitis guideline, currently the most up-to-date evidence-based guideline for managing infants with bronchiolitis. So, what did they find?

The evidence shows that there’s very little you can do in bronchiolitis other than supportive care.

Salbutamol, adrenaline and hypertonic saline nebulizers don’t work, steroids don’t work, antibiotics don’t work, and forget nasal suctioning… it doesn’t work. The only thing we can do is maintain oxygen saturations above 91%, support feeding and, as always, practice good hand hygiene. Oh well. We have a fab podcast guest featuring Fontanelle for all things bronchiolitis.

So, what happened to Finn? 

Finn’s sats were sitting at 89 to 90%, but with a little nasal cannula oxygen they picked up nicely to 93%. He couldn’t quite manage his bottles, so the nurses in ED popped in a nasogastric tube to support his feeding. Within 12 hours he was off oxygen and was settled enough for his first bottle. The very next morning he was looking grand so was discharged home, back to Galway.

Let’s jump ahead again to just after Finn’s third birthday. Finn loves watching his parents cast spells. He isn’t allowed to use his parents’ wands. But, like many inquisitive 3 year olds, he has a healthy disregard of rules and tries a little magic himself. Disaster strikes. There’s an explosion. It seems he’s inadvertently delivered an appendicitis mimic pain spell. Although soft and non-tender, his tummy is SO sore. Ron picks up the phone to dial 999 (which is now on speed dial). It’s not long before the paramedics arrive. There’s Ron wearily explains that the spell brings on a pain similar to appendicitis but without the need for surgery. The paramedics debate their options. The paracetamol and ibuprofen they’ve given Finn hasn’t taken the edge off. He’s too young for methoxyflurane or nitrous and although he looks like he needs an opiate, this isn’t trauma. Plus they’re worried about tipping him into respiratory depression. What should they do?

Murphy et al, 2014. A qualitative study of the barriers to prehospital management of acute pain in children. Emergency Medicine Journal

The literature shows us that adults are more than twice as likely to receive prehospital opiate analgesia for acute moderate to severe pain when compared with children who describe similar pain scores, with younger children often associated with the poorest acute pain management.

In 2014 a group of Irish PEM clinicians published this paper after interviewing 16 advanced paramedics from Dublin and Cork to find out what barriers they felt existed to achieving optimal prehospital paediatric pain control. Some themes became apparent:

The Clinical Practice Guideline at the time was limited when it came to paediatric pain. The only pain assessment tools included were the pain ladder or the Wong-Baker faces scale. And although Wong-Baker is great for the verbal child, it’s really not right for the younger tots. The analgesic choices to hand were also pretty limited; intranasal fentanyl wasn’t approved for prehospital use so the APs were given the option of paracetamol and ibuprofen, nitrous oxide (which children under 5 can’t manage because the coordination of inhaling through a mouthpiece is just too tricky) or IV opiates. Vascular access in a moving target is tricky at the best of times; but throw in a tiny vein, a screaming child and an emotional parent and it’s not all that practical.

The fear of administering morphine to small children was also apparent. Add to the mix limited exposure to children in the prehospital setting, short transfer times to the emergency department, and worry of slowing the respiratory rate and you can see why decent analgesia was difficult prehospitally.

Introducing the FLACC score and intranasal fentanyl to the CPG has worked wonders, especially for the kids with broken, bendy forearm fractures or obviously deformed lower limb fractures. But this hasn’t broken down the final barrier – the interviews highlighted medical causes of pain as being less likely to be treated aggressively. Which poses the question – Can opiate analgesia mask medical causes of pain?

The myth about withholding analgesia in patients with a suspected acute abdomen for fear of ‘masking clinical signs’ continues to be held by some clinicians. But it’s exactly that. A myth.

If a child has an organic cause of their abdominal pain, giving analgesia won’t hide the signs.

When their pain is controlled they’ll be so much easier for you to assess: an elevated heart rate in a well-analgised child will be a reflection of their illness rather than their distress and will allow you to treat to the best of your ability.

Feeling reassured, the paramedics score Finn’s pain. He’s squirming in pain, sobbing and impossible to console. He scores a 7 so they give him a dose of intranasal fentanyl. That doesn’t do the trick and 10 minutes later his FLACC score is still high so they give him another dose. And then because his pain continues to escalate they put in a line and give him a dose of IV ketamine. That works wonders and by the time they arrive at the hospital he is nicely settled. After some fluids and rest in ED, Finn is ready to go home. And the wands are locked out a certain curious pre-schooler’s reach.

Seven years later and Finn is now 10. Like most 10 year old wizards-to-be he REALLY loves flying on his broom. He was zooming around, swerved to avoid a pigeon and crashed straight into a tree. He’s pretty badly injured and an advanced paramedic crew is dispatched. By the time they arrive Finn looks awful. He’s maintaining his airway but his respiratory rate is up at 50 and his sats are in the 80s with bruising to the right side of his chest. His heart rate is 170 with a blood pressure of only 95 systolic. His GCS is 15. The paramedics get to work. Manual inline stabilisation in place, they know his chest is the issue. No breath sounds on the right and the chest is dull to percuss. Coupled with Finn’s haemodynamic instability, this looks like a massive haemothorax. They remember a paper called the Rule of 4s.

Teague et al, 2019. Rule of 4s: safe and effective pleural decompression and chest drain insertion in severely injured children. Emergency Medicine Australasia

This paper describes an aide-memoire for the time-poor clinician.

The authors give a fantastic step by step guide talking through each of the points above, including a photo of how to find the site of the safe triangle (bounded by the lateral edge of pectoralis major, the anterior border of latissimus dorsi and base of the axilla, and fifth intercostal space at the level of the nipple), how to make an incision and then push and spread through the intercostal muscles using mosquito or artery forceps, or a finger, depending on the age of the child.

Don’t worry about not having a chest drain. The priority prehospital is the thoracostomy.

Relieving a tension pneumothorax or massive haemothorax will save a child’s life.

But how often is a child likely to need a thoracostomy in the prehospital setting?

Quinn et al, 2020. Thoracostomy in children with severe trauma: an overview of the paediatric experience in Victoria, Australia. Emergency Medicine Australasia

This paper was published by the same team earlier this year. Looking back at 31 months’ experience of the Royal Children’s Hospital and Victorian Ambulance service up until February 2019, the paper describes the clinical stories behind children who’d had a thoracostomy for trauma prehospitally or in the ED.

During this time 8 children had prehospital thoracostomies performed by paramedics at the scene, half unilateral and half bilateral. All the children had had blunt trauma, most commonly motor vehicle accidents, closely followed by cars hitting children on their bikes or as pedestrians.

The two indications for thoracostomy were hypoxia and/or hypotension. Two children with hypoxia were also in traumatic cardiac arrest.

Needle thoracocentesis was performed in 10 children. All 10 required subsequent thoracostomy to relieve their haemo or pneumothorax. So put away those needles and grab the scalpels.

When the thoracostomies were performed, all 14 children had evidence of decompression of clinically significant haemothorax and/or pneumothorax. And really importantly, in all the cases, the indication for thoracostomy resolved or showed sustained and notable improvement post-thoracostomy. 

Prehospital thoracostomies in children sound pretty scary but I’d really recommend listening to Darren Hodge, a flight paramedic in Australia, as he describes his experiences of performing the first ever finger thoracostomy in a child in Melbourne.

 

The Advanced Paramedics who attend Finn use the Rule of 4s.

Site: They find the 4th intercostal space in the triangle of safety between the anterior and midaxillary lines and make a 3cm incision.

Push: They use artery forceps to push and dissect through the intercostal muscles and once into the pleural cavity they opened the forcep jaws to widen the hole.

Sweep: They make a big sweep with the forceps to clear a path for air and blood to exit.

Thoracostomy done, blood gushes out. Finn’s vitals improve significantly: his respiratory rate drops to 40, his sats improve to 96 and his BP picks up. They give him a bolus of fluid, package him up and get him to hospital. After some blood in the ED and a definitive chest drain he stabilises. He’s home a week later. The thoracostomy saved his life.

We’re time travelling one last time but thankfully this time, no injuries or illnesses come to pass. Finn, aged 15, is a model student, and although he’s inherited his father’s auburn locks and propensity for mischief, he has his mother’s brains. He’s a brave and kindhearted boy, and those qualities are incredibly important in a wizard. He writes an essay for about a paper he’s recently read.

Riskin et al, 2015. The impact of rudeness on medical team performance: a randomized trial. Pediatrics

Things go wrong in healthcare when clinicians are exposed to rude behaviour and this neat RCT illustrates it beautifully. 24 neonatal intensive care teams participated in a training simulation involving a very sick preterm infant with a surgical abdomen. The teams were told that a foreign expert on team reflexivity in medicine would observe them. The teams were then randomly assigned to either exposure to rudeness (in which the expert’s comments included mildly rude statements completely unrelated to the teams’ performance) or no rudeness (the expert just gave neutral comments).

When the videos of the simulations were watched back, and team scores were given for diagnosis and performance, they found that the teams who’d been exposed to rudeness had significantly lower scores than the other teams. It was clear that the teams just couldn’t perform as well when exposed to incivility. It is part of the evidence base on the amazing Civility Saves Lives website, which has loads of incredible resources for clinicians about the importance of civility.

Civility saves lives.

Finn wins first prize for his essay and graduates top of his class. Kindness remains his passion and he makes the hard decision to leave the beautiful island of Ireland. He flies to London where he works for the Ministry of Magic, deep underground in Whitehall.

 

    • To recap those prehospital PEM pearls:

      1. Reduce your cognitive load when it comes to any low-frequency but high-acuity events.
      2. Remember, wheeze in infants under a year is not the same as asthma.
      3. Don’t be afraid to give opiate analgesia to children, particularly in the non-trauma setting. It will never mask true pathology and will definitely help your clinical assessment.
      4. Having a robust system in place, like the Rule of 4s, will help when you’re faced with a highly emotive situation like life-threatening chest trauma.
      5. And finally, never forget, civility saves lives.

 

Wilderness Myths: Justin Hensley at DFTB19

Cite this article as:
Team DFTB. Wilderness Myths: Justin Hensley at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22390

Justin Hensley – the man with one of the best-kept beards in medicine – was exceedingly kind and filled in at the eleventh hour when one of the speakers had to pull out. Accompanied on stage by the youngest PICU fellow at the conference – his son, Jack – he busted some wilderness myths for the adventurous in the audience.

 

 

©Ian Summers

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal.

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