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.

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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COVID-19 and children: what do you need to know?

Cite this article as:
Boast A, Munro A. COVID-19 and children: what do you need to know?, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23868

In late 2019, a new infectious disease emerged and spread to almost every continent, called COVID-19. As of March 11th 2020 it was declared a global pandemic by the World Health Organisation, meaning that is was being spread among multiple different countries around the world at the same time. It has changed the way we live our lives.

What we understand about SARS-CoV2 and COVID-19 has increased dramatically, with research being done at an extraordinary rate. For those of us whose business is looking after children, what do we need to know?

 

Editor’s note: This post is based on what we know today, Wednesday 15th of April 2020, and will be updated as new information becomes available.

 

What is COVID-19?

  • COVID-19 is the name of the disease caused by a new coronavirus, which has been named SARS-CoV-2. COVID-19 is the disease, and SARS-CoV-2 is the virus.
  • A coronavirus is a type of virus named after its unique appearance – with a ‘crown’ of proteins – when viewed with high power microscopy.
  • Coronaviruses very commonly infects humans (and some animals).
  • In humans, coronaviruses are a frequent cause of the ‘common’ cold – resulting in an upper respiratory tract infection with cough and coryza. There are, however, three types which can cause severe, even life-threatening disease in humans (SARS, MERS, and COVID-19).

 

What is the difference between COVID-19, SARS, and MERS?

Whilst they are all severe illnesses caused by coronaviruses, there are some important differences. Some useful things to consider include the R0 (how many people, on average, one case of the disease will spread to in others) and the Case Fatality Rate (CFR), an estimate of how many people who contract the disease will die from it. Neither of these statistics is hard and fast (and are both highly context-specific), but they provide a rough yardstick with which to compare infectious diseases.

  • SARS: This is an acronym for Severe Acute Respiratory Syndrome, a disease caused by the virus SARS-CoV. In 2002-3 the spread of SARS-CoV resulted in around 8,000 cases, with a CFR of approximately 10%. Similar to COVID-19, SARS-CoV originated in China, before spreading around the world, predominantly Europe, North America, and South America. The R0 from SARS is thought to be 3.
  • MERS: This is an acronym for Middle East Respiratory Syndrome, caused by the virus MERS-CoV . As the name suggested, it originated in the middle east in 2012, transmitted initially from camels to humans. MERS causes the most lethal infection of the coronaviruses, with a CFR of around 35%. The R0 from MERS is thought to be <1.
  • COVID-19:This is an acronym for COronaVIrus Disease 2019, the disease caused by the virus SARS-CoV-2. It is a zoonotic disease (meaning it was transmitted to humans from animals) and although the intermediate host has not yet been identified, it’s thought to most likely have originated in bats. It was initially identified in December 2019 in China, before spreading around the world. The CFR is unclear, as it is still uncertain how many people actually have the virus, and how many who currently are unwell will die from the disease. The overall CFR is thought to be about 1.3%. This is highly dependent on the country (and available health resources) but another significant factor is age, with only a handful of deaths reported in children <12 years who have confirmed COVID-19. The R0 for COVID-19 is still unclear but is thought to be 2-3.

 

What are the symptoms?

  • The symptoms of COVID-19 are similar to other respiratory viral infections. Importantly, in children the symptoms of COVID19 are more likely to be mild, and a significant proportion may be asymptomatic.
  • Infected children who are symptomatic most commonly present with cough and fever.
  • A small proportion of children also present with gastrointestinal symptoms (vomiting or diarrhoea) (~10%)
  • Sore throat and runny nose do not appear to be uncommon features in children (as opposed to adults)

 

How does COVID-19 affect children?

Evidence from across the globe (namely China, Spain, Italy and America), has shown that children are significantly less affected by COVID19 than adults. There are both fewer cases in children, and less children who are severely unwell. Younger infants appear to be most likely to be hospitalised. Overall, there have been only a small number of deaths in children with confirmed COVID-19 reported. A number of epidemiological and clinical papers on COVID-19 in children have been published, summarised on DFTB.

The exact reason why there are so few children with confirmed COVID-19 is unknown. Initially it was thought that due to the high rate of asymptomatic infection children were simply less likely to be swabbed and have confirmed infection. However, recent evidence from Iceland, Japan and Korea shows that children may also be less likely to become infected with SARS-CoV-2 following exposure.

It is yet unknown whether asymptomatic children can pass the infection on to others. In epidemiological studies children have not been found to have a significant role in household transmission. It appears children may continue to excrete the virus through their faeces (poo) for several weeks after the symptoms of infection have passed, but the role of this excretion in viral transmission is not clear (there is some evidence to show it is only viral particles rather than active virus). Regardless, hand hygiene remains of paramount importance in reducing spread.

 

If my child is unwell, can I give them ibuprofen?

There has been considerable social media interest in the use of ibuprofen in suspected or confirmed COVID-19. In the UK, the MHRA has deemed there is no evidence of increased risk of using ibuprofen even in cases of COVID-19.

 

What about neonates?

Neonates without comorbidities do not appear to be at an increased risk. A large number of case series having been published of babies born to mothers with COVID-19. Although some neonates have swabbed positive for SARS-CoV-2, there have been no reports of this being associated significant illness. Evidence about the possibility of transmission from mother to baby in the womb is currently unclear.

In the UK, the RCPCH has published guidelines (with the Royal College of Obstetrics and Gynaecology) recommending pregnant women with COVID-19 who are in labour should deliver their baby in an obstetric unit, however there is no need to separate mother and baby after birth, and the benefits of breast feeding outweigh any theoretical risks. Of note, the American Academy of Pediatrics has released conflicting guidelines, suggesting separation of the mother and baby.

 

What about children with chronic conditions?

There is limited data to guide us currently on how COVID-19 might affect children with underlying health conditions. There are small case studies of children with suppressed immune systems who have not developed severe illness, including children treated for cancer and inflammatory bowel disease. There is some evidence that children with respiratory or cardiovascular comorbidities may be at higher risk of hospitalisation, but it is still unclear. For children currently being treated for cancer, the UK Children’s Cancer and Leukaemia Group have posted guidance for families including which groups are extremely vulnerable and should be “shielding”.

 

Is there any treatment?

There is no proven treatment for COVID-19, however, there are many clinical trials underway for many different therapies. The WHO has clearly stated that experimental therapies should only be used in the context of a clinical trial. Hydroxychloroquine and remdesivir have been studied most extensively, but there remains no clear evidence of benefit. Importantly, hydroxychloroquine has been associated with significant adverse effects, highlighting the importance of its prescription only in the context of a clinical trial.

Notably, there are only a handful of clinical trials for children registered, so it is unlikely that any therapeutics will be widely used in children with COVID-19. As the disease is generally mild in children, it is not likely to often be necessary to provide anything further than supportive care.

Vaccines will hopefully provide protection against future outbreaks of COVID-19, though these are still early in the drug development pipeline and unlikely to be available this year.

 

What can I do to minimize my risk?

Two words – hand hygiene. As with other viruses spread by droplet (e.g. influenza) hand hygiene, particularly when out in public, plays a critical role in preventing transmission. Washing hands with soap and water, for an adequate amount of time, covering all areas of the hands is most effective. Hand sanitizer is effective, but no more so than usual hand washing

It is important to avoid contact with others who are acutely unwell. Wearing surgical masks will not protect you from respiratory viruses. Wearing one if you are unwell may protect others from your respiratory secretions.

Physical distancing is becoming increasingly important, with many countries now mandating various ‘lock-downs’. You should follow advice from your public health authorities, and it would be wise to reduce non essential physical or close personal contact with other people to a minimum 

 

What should I do if someone in my family becomes unwell?

 

Resources for health professionals

Many journals have made their COVID-19 resources open access including NEJMThe LancetBMJ, and JAMA

National professional resources can be found at:

 

Literature

For a comprehensive review of all paediatric English language literature to date which has informed this article please see our separate page for COVID-19 Evidence

More questions than answers

Cite this article as:
Andrew Tagg. More questions than answers, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24133

Given the rapidly changing climate for all things COVID19 the DFTB wanted more information. We know our strength is in our community so we hosted a series of webinars linking healthcare workers with a special interest in paediatrics. No one person is an expert but we are all in the same situation facing similar challenges. These are some of the questions that came out of the discussions. With the proviso that information is changing on a daily basis and resources in terms of staff, space and stuff is different, let’s dive in.

This data is correct as of 19th March 2020. Please let us know in the comments if you spot anything new.

Science

NSAIDs

There has been a suggestion that non-steroidal agents are unsafe for use in SARS-CoV2-19 patients. As we have already seen the evidence for anything in the paediatric realm is very slim.  However, as of the 17th of March 2020 the WHO has recommended against using ibuprofen in patients with symptoms suggestive of COVID19. What does this mean in real terms? We don’t know which children are asymptomatic carriers.

If you look at the source of the message it is even more striking – the French health minister suggested that anti-inflammatory drugs could exacerbate symptoms. He suggested that we should not prescribe NSAID’s or cortisone/steroids to patients with suspected COVID19. Given that one of the few drugs that work in one of our more prevalent respiratory diseases, croup, is a steroid then I think we need to look to more evidence of harm over benefit. If you want a great, easy read on the matter then check out fullfact.org.

ACE-I

Very little is known on the potential impact of ACE inhibitors on COVID19 in adults, let alone children. The Venn diagram of children with the disease and on perindopril (say) is represented by two separate and distinct circles at the moment. If you are curious as to how there may be an interaction then read this great Tweetorial from Jonny Wilkinson.

It is also worth taking a looking at this letter in the Lancet to better understand the theory.

Fang L, Karakiulakis G, Roth M. Are patients with hypertension and diabetes mellitus at increased risk for COVID-19 infection?. The Lancet Respiratory Medicine. 2020 Mar 11.

Vaccines and various treatments

To claim that there is a cure just around the corner or that a certain combination of vitamins and herbs will keep the virus away is pure quackery. Rather than tell you what research is going on then dashing your hopes when there is a negative outcome we’ll reserve our judgement at this stage.

 

Sorting and Streaming

A common challenge mentioned by all sites is just how do we triage? How do we sort patients so that we are not mixing potentially infected with non-infected patients? There cannot be a one size fits all approach as the needs of a single provider clinic are every different from those of a district general hospital and these are very different from a tertiary paediatric centre. Rural and remote populations have different resources to the big, shiny hospitals complete with fish tanks and meerkat enclosures.

Triage

A number of hospitals are using a concierge based approach. As a patient approaches the department they are met by a greeter (who is usually a member of the nursing staff), dressed in full PPE. They help determine the first decision point – possible COVID19 or unlikely COVID19. The latter group is pretty easy to spot. Determining what patient sub-types fall into the former is more of a challenge. In the initial phase of the disease, most hospitals have looked for the presence of respiratory symptoms PLUS a fever. If you look at the published and pre-print paediatric data around 2/3 of children with the disease have a fever and a large proportion appear to be asymptomatic. A number of patients also present with predominantly GI symptoms. Should they be treated as potential carriers? (And who should change their nappies given they can shed SARS-CoV2-19 for up to 40 days?)

An alternative triage approach utilizes a more 21sst century solution with carers/patients logging important information on a tablet-style device before their secondary medical triage. This would require the user to clean the interface after use – something that is already tough.

Children with special medical needs

There is insufficient data to make hard and fast rules about the management of children with complex healthcare needs. Adults with multiple comorbidities have increased mortality so it is biologically plausible that the same will hold true in the paediatric population. Pre-notification of attendance can help as these kids are brought in via a different entrance.

Many places are trying to replace standard outpatient visits with telehealth options on an ad hoc basis with little guidelines available on how to do this without just picking up your own mobile phone. This is not an ideal solution but is being offered to many children with diabetes, chronic respiratory conditions or children with rheumatological conditions requiring immunosuppressive agents.

The RCPCH recommends that children who have an exacerbation of their chronic respiratory illness and require admission should be considered to have COVID19 until proven otherwise.

Internal streaming

Once the children have been streamed into a respiratory disease cohort should we assume they all have COVID19 until proven otherwise? Should we treat the patient with clinical bronchiolitis or croup as a potential carrier? And what about those that are wheezy but don’t have a fever? Just what do we do then?

The number of critically ill children presenting to the ED is likely to be small but it has been suggested that these are rapidly assessed and transported to a negative pressure room in PICU for the full workup, whether they need intubation or not.

Testing

Children do not come into the hospital on their own. They often bring carers, parents, grandparents, aunts and uncles. Adjusting the policy on attendant carers is a tough sell to those that are looking after the potentially infected child. Most mixed EDs seem to be keeping the family unit together for testing. It would be interesting to know if any tertiary paediatric centres are testing the grown-ups that come with the children.

Just how accurate is the PCR test? And just how long does it take a result to come back? We are looking into the former question and can sense the frustration around the latter. Cohorting patients in negative pressure rooms just waiting five days for a swab result is not helping us clear the decks. We should be mindful, though, that there are things we can control and things we cannot. This is one of those things we have no control over at the moment.

Mixed departments

Most of us do not have the luxury of working in a tertiary paediatric centre where the only adults are dressed as clowns or doctors (or doctor-clowns). Some departments are making provisions by moving their paediatric space to allow for adult overflow. The RCPCH has also stated that paediatricians should be prepared to see patients up to the age of 25. That makes sense in a mixed environment but one wonders what happens in centres that do not routinely see any adults. With outpatients and elective surgery being cancelled across hospitals, there is a potential surfeit of doctors with markedly reduced day to day work.

There is also the question of what happens in adult hospitals when a COVID19 positive sole parent gets admitted. What happens to their swab-negative child? In some cases, the decision has been to treat them as a boarder but this can make many staff members feel uncomfortable.

Sicker children

At the time of writing this the mortality in children is exceedingly low. This is very reassuring but business will continue as usual. Treatment options may be limited dependent on restrictions with regard to aerosol-generating procedures. There have been mixed messages as to whether nebulization of medication. leads to increased healthcare worker risk. Some places are now controlling the use of nebulized treatment, as well as mandating consultant approval of high flow nasal cannula oxygenation. In centre without access to a PICU on-site how are these children being managed? What have measures have paediatric retrieval services put in place to deal with the potential increase in referrals?

Intubation teams are already being considered at a number of sites – teams of doctors, similar to a MET team, that are ready to provide critical care at the sound of a bleep, in the hope that this will reduce exposure to one of the highest risk aerosol-generating procedures – intubation. In mixed adult/paediatric hospitals it is also important to consider the implications of intubation in a resource replete setting. Some hospitals are starting to consider this and set up ethics committees to set rules early and consider just who should have access to that last ventilator. The decision is not as easy as you think.

 

Stuff

Personal protective equipment

There have been some mixed messages about what type of PPE should be worn in what scenario.  Public Health England has this handy table to guide you and, as always, be mindful of your local guidelines if they differ.

Some hospitals are requiring all healthcare providers to undergo mandatory, face-to-face training in donning and doffing PPE prior to deployment. It has been suggested that we should wear the highest standard of PPE for every encounter in order to present nosocomial transmission. Unfortunately, supplies are limited and so we should use the most appropriate PPE for the task in hand.

Aerosol generating procedures

There seems to be a lot of confusion about what an aerosol-generating procedure is. As always, it is important to follow your local clinical guidelines. But if you disagree with them, then let the evidence guide you, and seek to change the guidelines. Concerns have been raised about everything from just examining the throat, using nebulizers (a daily question), and whether we should be using HME filters on the Neopuff. Rest assured we are looking at this and a blog post will follow.

 

Staffing

Rosters

We are already overstretched – both on the floor and in the back office. Corona conditions are making this even more apparent as we are wondering whether we should stretch our elastic workforce just that little bit more before the wave hits so that we have a rested and well cohort, ready to go. Those of us that work in mixed EDs know that paediatric workforce planning is furthest from our minds as we read of the Italian situation.

Should (when?) the pandemic stretch on for months considerations need to be given to staff longevity. Will there be a burnt-out generation of ED physicians who have seen and been exposed to too much? What about those who have had much-needed leave cancelled? Perhaps some of the daily load can be taken up with doctors from those specialities who have a lower case burden? Orthopaedic registrars could oversea minor-injuries clinics in a remote location. Dermatology trainees could answer the question of “What on earth is that rash?” in a medical/non-COVID assessment area?

Healthcare workers that work across sites are already being asked to reduce cross-campus travel.

Though we go to work for our patients we also need to be mindful that we too may become patients. None of us is immune to catching the disease. In its mild form, it will be an inconvenience to us, our loved ones, and our colleagues. But healthcare workers will die. Healthcare workers have already died. How do we mitigate the risks for the more vulnerable? What should we do with the older, more at-risk, paediatrician, the immunosuppressed healthcare worker, the pregnant trainee? These are questions that have not yet been answered.

Everyday life

As we are being asked to work longer hours how many hospitals have made provision for routine, everyday tasks? How many have designated areas for staff to catch some sleep before driving home? How many are providing scrubs for staff to change into or are helping with the laundry? The last thing most of us feel like when we get home is loading up the washing machine (and then putting it out to dry. But how clean are your everyday clothes? Your stethoscope? Your phone?

How are workplaces supporting that other basic physiological need – food? With supermarkets reducing their opening hours how are healthcare workers being supported? McDonald’s in the UK is offering free drinks to those with NHS cards but you can only last so long on caffeinated brown water.

Information dissemination

The situation with SARS-CoV19-2 is a rapidly evolving one with advice changing on a daily basis. Most hospitals have set up incident management teams that meet at an executive level to discuss the changes that may impact our day to day – cancelling elective surgery, moving departments. Making sure that information trickles down from an operational level to a clinical level can be hard, especially with a workforce that might be relying on bank or agency staff. A lot of departments are trialling WhatsApp groups as a means of sharing the very latest information but it is still possible for a key piece of information to be lost in the stream.

Education

Most hospitals have now cancelled face-to-face education sessions. There are plenty of of resources available to help educators plan sessions remotely. This series from ALiEM is the standout.  The DFTB team hope to be adding more resources for you shortly (especially if we get put in isolation).

Students

A number of universities have pulled their students from clinical placements or placed restrictions on their interactions with patients e.g. not to see a respiratory patient. Many feel that they should be doing something and a number of great initiatives have been suggested. One group has launched a childcare service for healthcare providers. With schools in the UK due to close early for the Easter break this will come as a welcome relief to many who may usually rely on (at-risk) relatives. It has also been suggested that they would make excellent scribes to speed up the standard clerking process. Let us know what else is going on.

Morale

At the moment we are all nervous anticipation, stepping over wavelets or paddling our boards out ready to catch the big wave. This sense of nervous excitement is palpable in the emergency room. The feeling getting is getting stronger as regular hospital services wind down. How do we maintain our own morale in the face of hard shifts? How do we look after each other when a colleague gets ill? How do we make sure that strangers fro other services are welcome in the safe space we call work?

 

At this time of great uncertainty, it is important that we remain kind, that we show #PandemicKindness to those we meet. Everyone is working their hardest and to the best of their abilities. Take time to recognise that, whether it is the security officer that has to ask you for your ID to allow you into the building or the cleaners that we rely on. Take your time to thank them for their hard work, offer them a coffee (or a tea if they are in the Northern hemisphere. Remember that the ED is often overstretched so that serum rhubarb may not have been ordered. Be mindful that those of us who are dealing with adults as patients too and recognise that they need our kindness now, more than ever.

Please feel free to answer any of these questions in the comments section. Share your resources, your experiences, so that we may learn from each other. E-mail us at hello@dontforgetthebubbles.com with your ideas and suggestions. And be safe.

Communicating with children with additional needs: Liz Herrieven at DFTB19

Cite this article as:
Team DFTB. Communicating with children with additional needs: Liz Herrieven at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21387

Communication is vitally important in so much we do as clinicians.  Without good communication we can’t hope to get a decent history, properly examine our patient, explain what we think is going on or ensure appropriate management.

Prematurity for the acute paediatrician: Camilla Kingdon at DFTB19

Cite this article as:
Team DFTB. Prematurity for the acute paediatrician: Camilla Kingdon at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22288

Camilla Kingdon is the Vice President for Education and Development at the Royal College of Paediatrics and Child Health. Her day job is working as a neonatologist at Evelina London Children’s Hospital.

Whilst the core work of a neonatologist takes place behind closed doors in the safety and security of the NICU babies do not choose where or when they are born. Sometimes, just sometimes, they like to surprise us and pop out early, when we least expect it. What do we do then?

 
 
#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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Ankle sprains

Cite this article as:
Neil Thomspon. Ankle sprains, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22248

David, 11, intends to play football in the Premier League when he is older.  Before then, he must serve his time with the school team.  During training, he ships a heavy tackle and rolls over his ankle. He limps over to the sideline and calls for help. Taking no risks with his future star, the coach insists mum takes him to ED. You are waiting with your game face on.

Having seen one or two sore ankles before, you are aware of the Ottawa ankle rules, but what are they? And are they applicable in kids?

 

Ottawa ankle rules

The Ottawa ankle rules are an evidence-based decision tool to advise indication for x-ray in an ankle injury.

An ankle x-ray series is required if:

There is any pain in the malleolar zones and…

  • bony tenderness over the posterior aspect of distal 6cm of tibia (i.e. medial malleolus)

OR

  • bony tenderness over the posterior aspect of distal 6cm of fibula (i.e lateral malleolus)

OR

  • inability to weight bear (>4 steps) both immediately after the injury and in the ED

 

A foot x-ray series is required if:

There is any pain in the midfoot zone and…

  • bone tenderness at the base of the 5th metatarsal

OR

  • bone tenderness at the navicular

OR

  • inability to weight bear (>4 steps) both immediately after the injury and in the ED

 

Practice common sense – these rules are not applicable if your patient is: unable to give a reliable answer; has other distracting injuries; has diminished sensation in legs; is too swollen to establish bony tenderness; unable to walk prior to the injury.  Remember that a patient who walks with a limp is able to weight bear.

The rules were designed with adults in mind, however, they have been shown to be reliable in the assessment on children. They are sensitive but not specific for detecting fractures, therefore, they are most useful in ruling out fractures (and the need for imaging).  For every 1000 patients that exhibit negative Ottawa ankle rules, 14 will actually have fractures.

 

David does not meet the criteria for imaging.  He does have a swollen ankle with tenderness over the anterior aspect of his lateral malleolus.  You suspect an ankle sprain.

 

What is an ankle sprain?

A sprain occurs when you stretch or tear a ligament.

Symptoms include pain, swelling, bruising, tenderness, impaired function and joint instability (if severe).

Classification of a sprain:

  • Grade 1 is stretching of the ligament, minimal swelling or bruising, no joint instability
  • Grade 2 is a partial rupture of the ligament, moderate swelling or bruising, no joint instability
  • Grade 3 is total rupture of the ligament, severe swelling or bruising, with joint instability

There are three main sets of ligaments in the ankle

  • Lateral – Anterior Talo-Fibular Ligament (ATFL), Calcaneo-Fibular Ligament (CFL), Posterior Talo-Fibular Ligament (PTFL)
  • Medial – Deltoid ligament
  • Interosseous (tibiofibular) ligament

There are two tests for instability, which should be compared between the good and bad ankles:

  1. Anterior drawer test – stabilize the leg with one hand, use the other hand to cup the heel and draw the foot anteriorly. If there is excessive movement then the test is positive.
  2. Talar tilt test – stabilize the leg with one hand, use the other hand to cup the heel and rock the foot in an inversion movement. If there is excessive movement then the test is positive.

 

How should I manage an ankle sprain?

A simple PRICE approach, along with analgesia, is the first line of management:

Protection. For example, with a supportive boot.

Rest. Usually for 72 hours.

Ice. Cover ice in a tea-towel and apply to the ankle for 10-15minutes every 2-3 hours.

Compression. An elasticated bandage will help with swelling and provide some support (but should be removed at night).

Elevation. Elevate the ankle until the swelling goes down.

Early mobilization as tolerated will facilitate faster recovery, however more severe sprains may require a period of immobilization. (7-10 days).

Supervised physiotherapy has been shown to benefit in early follow-up but does not make a difference in the long term.

What is the prognosis?

The recovery period depends on the severity of the sprain. A grade 1 sprain may return to play in 1-2 weeks; whilst a more severe sprain may return to walking in 1-2 weeks, running in 6-8 weeks and return to regular sporting activity in 8-12 weeks.

 

David’s ankle was strapped up in a Tubigrip and he limped home, eager to get back on the pitch and continue his journey to stardom.

Procedural sedation

Cite this article as:
Tadgh Moriarty. Procedural sedation, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23718

Sometimes we have to do things that children don’t like. These procedures may be scary, or potentially painful. In this post, we’ll cover a few of the more common techniques.

 

Case one: Kayla

Earlier this month, the UK Royal College of Emergency Medicine, RCEM, published new guidance on the use of ketamine for procedural sedation in children in the emergency department, superseding their 2016 guidelines. Follow Kayla through her ED visit as she helps us explore the changes RCEM recommends.

 

It’s 3 pm on a busy Friday afternoon on your PEM shift. You have just seen Kayla, a 20-month-old girl who fell from onto a concrete step and sustained a nasty L-shaped laceration to her thigh. You have satisfied yourself that her joints are not involved, and an x-ray reveals no underlying fracture. You can see a large amount of debris within the wound. Her vaccines are up to date and she has no significant medical history. She is, however, eating a large ice cream cone that her parents had purchased to pacify her. You wonder how best to proceed as you have a nasty wound that needs thorough irrigation and closure. A toddler is unlikely to tolerate local anaesthetic infiltration as the primary means of anaesthetising the wound.

 

Does Kayla need procedural sedation?

Paediatric Procedural Sedation (PPS) aims to alleviate the distress around painful procedures but should not be viewed as a substitute for good pain relief. Maximize analgesia and recruit any distraction devices to hand (iPads / parents / play specialists – these are a particularly excellent resource and should be utilized wherever possible).

Is the wound suitable for ‘LAT gel’? This revolutionary gel which combines lignocaine, adrenaline and tetracaine can prevent many sedations when used correctly. It takes 30-60minutes to be fully effective after application so be sure to allow sufficient time. Even if the patient is progressing to procedural sedation this gel will help with local anaesthesia and analgesia.

The ability to perform PPS will be based on current acuity within the department, available resources, and appropriate staffing skill mix. The three main agents used for procedural sedation in paediatrics are midazolam, nitrous oxide, and ketamine.

 

Kayla’s LAT gel has been in situ for half an hour. You return to the cubicle armed with a play specialist and nurse, along with your irrigation and suturing materials. Despite a stellar sock puppet show by your play specialist, loud sing-along songs, and Peppa Pig showing on the iPad, your attempt at irrigation is futile; Kayla remains upset. You decide PPS is needed to ensure effective irrigation, neat wound closure, and avoiding further trauma to an upset child (and mother!)

 

Which agent is best suited?

You need to consider what you hope to achieve with sedation and what level of experience and resources are available currently in the department to aid in answering this question. The spectrum of use varies from diagnostic imaging, through minimally painful procedures (e.g. foreign body removal, vascular access), to painful procedures (e.g. fracture reduction, wound washout and closure). The choice of agent, therefore, will reflect the individual patient (anxiety, co-operative, parental preference), and the staff available at the time.

 

Kayla requires a short painful procedure to be carried out and nitrous oxide or ketamine would be suitable. As you start showing her the face mask for nitrous, Kayla freaks out – Kayla had a slightly traumatic experience with a bronchodilator and spacer, her mother explains. There’s no way you’re going to get Kayla to cooperate with the nitrous mask. So ketamine is selected as the agent of choice.

Just as you are about to begin the pre-procedure assessment one of the student nurses who will be observing the procedure tells you that she has seen a lot on Twitter about the new RCEM ketamine PPS guideline recently but is unclear as to exactly what ketamine is and why it’s useful in paediatrics.

 

Ketamine is an NMDA receptor antagonist. It is a dissociative anaesthetic and potent analgesic and amnesic. Rather than the typical ‘sleep‘ which results after administration of other anaesthetic agents, ketamine induces a trance-like state, oftentimes with the patient’s eyes open but ‘nobody home‘ (it is important to warn parents beforehand about this as it can be quite scary if unexpected). Some of the many benefits of ketamine are that airway reflexes are maintained, while is augmented heart rate and blood pressure (for the most part – in the compromised circulation bradycardia and hypotension can occur).

 

The pre-sedation assessment

You begin Kayla’s pre-sedation assessment. Your assessment includes a focussed history: has Kayla undergone any previous anaesthesia or PPS? If so, did she have any reactions or adverse events? Does she suffer from any chronic medical conditions, take any regular medications or have any drug allergies? Does Kayla have any concurrent medical conditions – especially active asthma, respiratory tract infection or tonsillitis?

You then examine Kayla, ensuring you conduct as cardiorespiratory exam and an assessment of her airway anatomy, including ASA grade. You need to assure yourself that no contraindications exist.

 

RCEM’s 2020 guidance is very specific about the need for conducting a thorough pre-sedation assessment, including assessing ASA grade, all of which should be thoroughly documented for clinical auditing and safety purposes. An example proforma template is provided at the end of their guideline. This contrasts with the 2016 guideline, which included a list of contraindications, but did not require documentation of ASA grade.

 

It’s time to consent Kayla and her mum for the procedure. You remember that ketamine is considered safer than other hypnotic drugs such as Propofol but need to remind yourself of the specifics, and the side-effect profile prior to consenting.

 

How safe is ketamine?

Does ketamine have side effects? Yes, but of all sedation agents studied by Bhatt et al in 2017 (6,760 patients across 5 sites in Canada), ketamine came out on top. This looked at ketamine/propofol, ketamine/fentanyl, propofol alone and ketamine alone. There were 831 adverse events across all agents (11.7%) – these included oxygen desaturation (5.6%) and vomiting (5.2%). There were 69 (1.1% of cases) serious adverse events (SAE). Ketamine as single-agent had the lowest SAEs at just 0.4%.

Pre-procedural opioids and laceration repair were associated with increased risk of emesis. Bhatt et al noted that prophylactic antiemetics reduce the risk of vomiting by half, but these were not needed in those under 5 years of age due to the low overall risk of emesis.

This endorsed previous data from a large case series by Green et al (2009) which demonstrated low rates of adverse events with ketamine PPS; most notably, noisy breathing (not requiring any intervention other than airway repositioning) occurred in 1%, laryngospasm in 0.3% and of these only 0.02% required intubation.

Both of these large studies demonstrate ketamine’s excellent safety profile when used with the appropriate preparation and patient selection.

 

Does Kayla need to have fasted?

Let’s have a look at the current guidelines and evidence. Several large studies have looked at this controversial issue: one study in a US PED in 2001/2002 where only 44% of patients met traditional fasting guidelines demonstrated no statistically nor clinically significant increase in adverse events in the unfasted population.

A series of over 30,000 children undergoing PPS by Cravero et al (2006) reported only 1 episode of aspiration – and this was in a fasted patient!

In 2016, Beach et al published a report based on 140,000 procedural sedation events, noting that aspiration was a rare event. Furthermore, they concluded that non-fasted patients were at no greater risk of major complications or aspiration than fasted patients.

In 2014 the American College of Emergency Physicians (ACEP) altered their national guidance stating that procedural sedation “should not be delayed for children in the ED who have not been fasted.” This was based on a systematic review including 3,000 sedation events showing that pre-procedural fasting failed to reduce the risk of emesis, aspiration, or other adverse events. They acknowledged that the current evidence does not support the rationale put forth in the non-emergency medicine guidelines that adherence to minimum fasting times decreased adverse events in ED procedural sedation.

 

This is reflected in RCEM’s 2020 guidance, which states that there is no evidence that complications are reduced if the child has fasted. They advised that the fasting state should be considered in relation to the urgency of the procedure, but recent food intake should not be considered as a contraindication to ketamine use.*

 

*We cheered when we read this in the 2020 guideline. No more fasting – we’ve been saying this for years! But, a quick look back at the 2016 guideline shows that this was actually the recommendation back then too. Really careful scrutiny shows that a single word, “however”, has been removed from the start of the sentence, “traditional anaesthetic practice favours a period of fasting”, altering the tone of the recommendation to a much less dogmatic mandate about nil by mouth status.

 

Satisfied that the evidence does not suggest any advantage to fasting children before PPS (who, let’s face it, tend to be less cooperative when hungry anyway), you prepare the room, staff, and equipment for the procedure.

 

Where will Kayla’s procedure be carried out, how many staff do you require, and what equipment should get ready?

 

RCEM recommends at least three operators: the proceduralist (the clinician performing the procedure), the sedationist (clinician responsible purely for managing sedation) and a sedation assistant*. They specifically acknowledge that the clinician responsible for the sedation and the patient’s airway should be experienced in the use of ketamine, and capable of managing its complications. The 2020 guideline has elaborated further on this, coming with a recommendation for a need for suitable training, a minimum of six months’ experience in anaesthesia or intensive care medicine and an up-to-date APLS course.

*RCEM says ‘nurse’ for the third member of staff but really, it’s anyone who is experienced in monitoring children and supporting the sedationist – doctors can take on this role too.

ACEP’s 2014 position statement concurs with the need for three operators.

The recommendation is that the procedure should be carried out in a resuscitation bay or high dependency area with immediate access to full resuscitation facilities.

Monitoring (every five minutes) of heart rate, blood pressure, respiratory rate, and oxygen saturation is mandated. The American Academy of Pediatrics advised the use of capnography as an adjunct in order to detect hypoventilation and apnoea earlier than pulse oximetry or clinical assessment alone. While no evidence currently shows capnography reduces the incidence of serious adverse events, available studies show a decreased incidence of hypoxia and respiratory events.

 

The use of capnography during sedation has been affirmed by RCEM who have made it a mandatory minimal requirement in their most recent guideline iteration, in parallel with their previously recommended monitoring of respiratory rate, heart rate, oxygen saturations, ECG and BP.
The 2020 RCEM guideline also includes ‘degree of dissociative sedation’ as part of its recommended monitoring during the procedure, which is a new addition to their guidance. Ketamine is unique in that it does not conform to the ‘sedation continuum’ – the patient is either dissociated or not. This recommendation is perhaps aimed at prompting the sedation clinician and nursing colleague as to whether dissociation has occurred, and as to whether a top-up dose is required (more on that later).
The updated RCEM document specifically advises having key resuscitation drug dose calculations performed prior to the procedure and ready access to these, another new addition to their guidance, although no specific drugs are recommended.

 

Some doses you may find useful are:

As you’re checking the ketamine and emergency drug doses with your nursing colleague she asks whether you want her to draw up atropine and midazolam? She is a recent addition to the ED team and mentions that when she worked in theatre some years ago they frequently gave these medications together with ketamine.

 

Should any adjunctive agents be used with ketamine?

There was a previous vogue to co-administer a benzodiazepine to reduce the incidence of emergence. A 2018 BestBets review looked at this very question by studying 6 relevant studies (including 2 RCTs: Sherwin et al 2000, and Walthen et al 2000). These failed to demonstrate a significant difference in emergence between ketamine alone and ketamine with midazolam. In fact, the only difference demonstrated was increased rates of adverse advents when a benzo was co-administered. So, no prophylactic benzodiazepine required.

Having said this, if a child suffers severe emergence (older children, in particular, have increased risk of recovery agitation), then it is worth considering midazolam (aliquots of IV 0.05-0.1mg/kg) to treat (but not routinely or for minor / moderate emergence).

Another previous trend involved the co-administration of atropine to reduce the risk of aspiration. But the evidence does not support this practice, Green et al concluded “There is no evidence to support routine use of anticholinergic medication such as atropine to prevent laryngospasm or other adverse airway events.” Concurrent anticholinergics may actually increase the rate of airway and respiratory adverse events. There is a small increased risk of laryngospasm with oropharyngeal manipulation (including suctioning) so atropine (20 micrograms/kg IV) may be considered as rescue therapy if PPS is being used for intraoral laceration repair (although RCEM would recommend not using ketamine for these procedures for this precise reason).

A common side-effect of ketamine is vomiting. RCEM’s 2020 guidance recommends the use of IV ondansetron at 0.1mg/kg (max dose 4mg) to treat intractable vomiting.

Given ketamine’s emetogenic properties, is it worth giving an antiemetic prophylactically? It is worth considering ondansetron (0.1mg/kg IV) as prophylaxis in high risk groups: those with previous nausea/vomiting during sedation/anaesthesia, older children, or IM administration. The NNT depending on age of the patient will lie between Var7 and 9. This was further endorsed by a BestBets review published in the EMJ in 2018 which concluded that ondansetron should be considered when using ketamine for PPS, especially in older children or for those receiving preprocedural opioids. As with any drug, however, you’ll need to balance the risk-benefit ratio in your mind. Some would prefer not to use ondansetron prophylactically because of the risk of arrhythmias in children with undiagnosed long QT. But, again, long QT is rare…

 

A resus bay is prepped. Kayla and her mother are ready. Roles have been allocated; your nursing colleague is ready and is just removing the Ametop from Kayla’s hands which had been applied when PPS was considered; one of the ANPs will be the procedural clinician and your consultant will supervise you as the sedation clinician. You cannulate first go, while Kayla is distracted by Peppa Pig on screen. It’s time to dissociate.

 

But what dose will you give Kayla?

Various opinions exists regarding the exact or perfect dose; the most commonly accepted dosing schedule is 1-1.5mg/kg for intravenous (IV) administration.

 

RCEM’s guideline recommends a starting dose of 1mg/kg over 60 seconds (to reduce adverse events such as laryngospasm). This can be supplemented with top-up doses of 0.5mg/kg. This has not changed from their previous guidance.

 

You should notice onset of action within a minute. It is easy to spot as the child will develop horizontal nystagmus coupled with a loss of response to verbal stimuli. The heart rate, blood pressure and respiration rate may all increase slightly. Sedation will start to wear off after 20 minutes, with full recovery should occur by about 60 to 120 minutes.

Many departments are still using intramuscular (IM) ketamine. This can be particularly helpful in certain situations such as where IV access is difficult.

 

Due to its variable onset and offset time, longer time to recovery and increased risk of emesis, however, RCEM have now advised against IM except where senior decision-makers deem it necessary. The advice is that “clinicians should be mindful of the perceived safety benefits of having intravenous access from the start of the procedure to mitigate a rare adverse event.” This is the biggest change in their new guidance; the 2016 guideline included dosing and top-up recommendations for IM ketamine.

 

There are still some children who would benefit from IM ketamine, so if choosing the IM option, consider a dose of 2-4mg/kg, with senior clinical support. Ideally IV access could be achieved once the child is dissociated and the IV top-up dose can be administered if required. However if IV access is impossible or not obtained the IM top-up dose is 1-2mg/kg. You can expect a slightly slower onset at about 3-5 minutes with its duration extended from 15-30minutes. Recovery is variable occurring anywhere between 60-120 minutes.

 

As you walk over to the drug cupboard to collect your syringes with carefully calculated doses, your consultant asks, “Are you confident in managing any potential airway complications?”

 

Airway complications with ketamine PPS

Thankfully complications with ketamine are rare. Most events such as noisy breathing or stridor, and minor desaturation will respond to simple airway manoeuvres to ensure the airway is open, plus the use of high-flow oxygen via a mask with a reservoir bag. The most feared complication, laryngospasm, is extremely rare and most often will respond to simple airway manoeuvres. But sedationists must be competent in managing this prior to administering the first dose of ketamine. If laryngospasm is suspected, stop the procedure and call for help. Ensure 100% oxygen is administered if not already in situ. Gently suction any visible secretions. If this fails to improve the situation begin manual ventilation with ventilation via a bag-valve-mask or, if you are comfortable using an anaesthetic circuit, apply PEEP. Some guidelines (and anaesthetists) suggest applying pressure to Larson’s point, very similar to performing a strong jaw thrust. If there is no response at this point, with critical airway compromise, then RSI is required. Administer the pre-calculated dose of paralytic and intubate. Remember, Green’s reported incidence of intubation secondary to laryngospasm was only 0.02%.

The flowchart below may be of benefit – it formed part of my quality improvement project on PPS and was used as a wall chart in the sedation cubicle and included in each sedation proforma booklet. When emergencies occur, being able to cognitively offload by following step by step aide memoires and having pre-calculated doses to hand can be immensely comforting and helpful.

 

 

Kayla’s procedure is completed without difficulty and the nurse enquires as to how long Kayla needs to remain monitored for?

 

Children should remain monitored until their conscious state, level of verbalization and ambulation is back at pre sedation levels. They should be able to tolerate oral fluids. Prior to discharge, a final set of observations should be within normal limits for their age. Consider the need for a prescription (antibiotics or analgesia) prior to discharge.

 

Kayla successfully underwent ketamine PPS, allowing a thorough wash out of her wound and suturing which provided a tidy end result. She was later discharged with an antibiotic prescription and a teddy which the play specialist had found in the toy room for her. Delighted with your chance to use “Special K”, you quickly took out your phone to tweet about the latest changes in RCEM guidance in ketamine for procedural sedation in children in the ED (along with the endless uses of ketamine!)

 

The new RCEM guidance has come at an interesting time – how might it change our practice in PPS in the ED? PERUKI are soon to launch a two-level paediatric procedural sedation survey (name PoPSiCLE – we all know that a good study needs a catchy name) to inform the current status and variations in the practice of PPS in PERUKI , to provide baseline information for developing a network-wide training resource and patient registry. Watch this space…

 

Case two: Ronan

 

It’s a sunny Saturday afternoon. The smell of BBQ and summer is wafting through some open windows in the department. On your way to work, you noticed plenty of bouncy castles and trampolines in use. It’s not surprising your first patient is an 8-year-old boy who has fallen awkwardly while trying to impress some other kids at his birthday party. After examining him and his xray you see he has a midshaft radius and ulnar fracture with some angulation. Thankfully his DRUJ (distal radio-ulnar joint) appears intact, and his radial head is in joint. He needs manipulation of the fractures and application of a backslab. He’s in a lot of pain, despite the paracetamol and ibuprofen he had at triage. He tells you his favourite birthday cake is at home waiting for him and he wants to get home to blow out all the candles. You wonder if you can avoid him a trip to the operating room for a general anaesthetic. Would PPS perhaps be a safe alternative?

 

Nitrous oxide provides anaesthesia, anxiolysis, and also some mild amnesia. However, it offers limited analgesia and so co-administration of an analgesic is recommended. Several key papers, including the FAN study (2017) and Seith et al (2012) have demonstrated the safety and efficacy of co-administrating intranasal fentanyl (INF) with nitrous oxide.

Once you’re ready to go, move the child into the dedicated resus bay or sedation room. If using piped nitrous oxide with a variable concentration flow meter (ensuring the scavenging system is switched on) titrate the dose from 30-70% according to clinical response. The alternative is Entonox (a 50/50 mix of nitrous and oxygen) which usually comes in portable canisters but requires the child to be able to take a deep breath to overcome a demand valve circuit, usually tricky for the under-fives. You should notice the onset of effect in 30-60 seconds, but its peak effect will be 2-5 minutes so best to wait for this before commencing the procedure. Once the intervention or procedure is completed it is important to administer 100% oxygen for 3-5minutes post-procedure to avoid diffusion hypoxia. The offset of effects should occur within 2-5 minutes.

Does nitrous oxide have any side effects? While well tolerated by most children, transient minor side effects such as nausea, dizziness and occasionally nightmares can occur. It can cause vomiting in 6-10% of children receiving 50% nitrous dose. This rate increases with higher concentration and can increase up to 25% if an opioid is co-administered. Be sure to warn parents about this relative frequency of vomiting when using nitrous oxide, both during and after sedation. The risk of vomiting also increases with a longer duration of nitrous administration. Consider a prophylactic antiemetic if the child has a history of nausea or vomiting.

Nitrous oxide diffuses through tissues more rapidly than nitrogen alone and can expand in air-containing spaces within the body. This makes it contraindicated for use in patients with gastrointestinal obstruction, pneumocephalus, pneumothorax and after diving.

Nitrous oxide inactivates the vitamin B12-dependent enzyme, methionine synthase, and so can deplete vitamin B12 stores. Because of this, caution is advised in those at risk of vitamin B12 deficiency such as vegetarians, patients with gastrointestinal disorders and those taking regular H2 receptor blockers and proton pump inhibitors. Nitrous should also be avoided in those with metabolic diseases especially methionine synthase deficiency, methymalonic acidaemia, and homocysinuria (because inactivation of methionine synthase can affect homocysteine metabolism). There’s a theoretical risk to pregnancies in the first trimester and so guidance often suggests avoiding nitrous oxide exposure in early pregnancy.

During administration monitor heart rate, respiratory rate and oxygen saturations. At least two staff members are required; a sedationist and a proceduralist.

 

Ronan and his mum are happy for you to use nitrous oxide and eagerly his mum signs the consent form. While setting up the sedation room and recruiting a nursing colleague to assist, you administer intranasal fentanyl. Ronan successfully undergoes manipulation of his fractures and an above elbow backslab is applied. His post-reduction x-ray shows you performed a pretty awesome reduction and, in consultation with your orthopaedic colleagues, you are happy for Ronan to be discharged to return to their fracture clinic in a few days’ time. This delights Ronan, as he gets to return home to his birthday party (with strict instructions to remain off the trampoline) and he promises to bring you back some of his birthday cake later!

 

 

Case three: Chantelle

Your junior colleague has come to you for advice. She has just seen a 4-year-old girl who was hard at work in her playroom creating unicorn pictures. Her mum had given her lots of colourful supplies including some glittery sequins and beads. Chantelle became adventurous and decided to decorate herself rather than the unicorns. Unfortunately, one of the beads has become lodged in her ear and despite an attempt by your colleague using both parents, and a play specialist, the removal of the foreign body was unsuccessful. You believe the use of PPS will be required and begin pondering which agent to use.

 

Midazolam is a hypnotic agent providing anxiolysis and amnesia. It does not have analgesic properties, which is why it is important to co-administer with analgesia for any painful procedure. It can be administered by many routes, the two commonest for PPS being intranasal (IN) and orally. If used intranasally, a dose of 0.3-0.5mg/kg is suggested. You should notice its onset within 10-15 minutes, lasting about 60 minutes. This route of administration can cause some nasal irritation and burning, so some clinicians prefer to use it orally. With an oral dose of 0.5mg/kg you should notice onset at 15-30 minutes with a duration of effect for 60-90 minutes. Midazolam tastes bitter – so give it with some juice or squash to make it more palatable. Midazolam can be given intramuscularly (IM) and intravenously (IV), but it is less likely to be used in this fashion for PPS.

Does midazolam have any side effects? Yes! It can cause hypoventilation and apnoea – be aware that this risk is increased if co-administered with an opioid such as fentanyl or diamorphine. A reversal agent does exist: flumazenil (0.01mg/kg, max dose 1mg) but this is rarely required, and oftentimes using basic airway manoeuvres is sufficient. Paradoxical excitatory or agitation reactions can occur in up to 15% of children. Do warn parents of this possibility prior to administration. The best course of action if it does occur is to let the child “ride it out”. Because of this, many ED clinicians will choose ketamine or nitrous oxide as their PPS agent of choice over midazolam.

With these side effects in mind, it is prudent to ensure basic monitoring includes heart rate, respiratory rate, and oxygen saturation monitoring. At least two staff are required; proceduralist and sedationist.

 

Having obtained informed consent from Chantelle’s mother, you decide to give her intranasal midazolam. 45 minutes later you remove the mischievous bead from her left ear. Her parents are thrilled, but before you leave the room you remember the mantra of “always check the other ear”. So before packing up your tools and leaving her with your sedation nurse, you decide to check her other ear. Interesting you find two glittery sequins hiding in her right ear canal. Phew, that saved a second sedation event!

 

References

Ketamine Procedural sedation for children in the emergency department. The Royal College of Emergency Medicine. Best Practice Guideline. February 2020.

Bhatt M, Johnson DW, Chan J et al. Risk factors for adverse events in emergency department procedural sedation in children. JAMA paediatrics 2017 Oct 1;171(10):957-964

Bhatt M, Johnson DW, Chan J et al. Risk factors for adverse events in emergency department procedural sedation in children. JAMA paediatrics 2017 Oct 1;171(10):957-964

Green SM, Roback MG, Krauss B, et al. Predictors of airway and respiratory adverse events with ketamine sedation in the emergency department: an individual-patient data meta-analysis of 8,282 children. Ann Emerg Med. 2009; 54(2):158-168.e1-4

Agrawal D, Manzi S, Gupta R, Krauss B. Pre-procedural fasting state and adverse events in children undergoing procedural sedation and analgesia in a paediatric ED. Annals of Emergency Medicine. 2003; 42(5): 636-646

Cravero JP, Blike GT, Beach M, et al. Incidence and nature of adverse events during pediatric sedation/ anesthesia for procedures outside the operating room: report from the Pediatric Sedation Research Consortium. Pediatrics. 2006; 118(3):1087-1096

Beach ML, Cohen DM, Gallagher SM, Cravero JP. Major Adverse Events and Relationship to Nil per Os Status in Pediatric Sedation/Anesthesia Outside the Operating Room: A Report of the Pediatric Sedation Research Consortium. Anesthesiology 2016;124(1):80-8

Godwin SA, Burton JH, Gerardo CJ, et al. Clinical policy: procedural sedation and analgesia in the emergency department. Annals of Emergency Medicine 2014;63(2):247-58.e18

Sherwin TS, Green SM, Khan A, et al.Does adjuctive midazolam reduce recovery agitation after ketamine sedation for pediatric procedures? A randomised, double-blind, placebo-controlled trial. Ann Emerg Med 2000;35:229–38.

Walthen J, Roback M, Mackenzie T et al. Does midazolam alter the clinical effects of intravenous ketamine sedation in Children? A double-blind, randomized, controlled, emergency department trial. Annals of emergency medicine 2000;36(6): 579-587

Green SM, Roback M, Kennedy R et al. Clinical practice guideline for emergency department ketamine dissociative sedation: 2011 update. Annals of emergency medicine 2011; 57(5): 449-461

Dunlop L, Hall D. Antiemetic use in paediatric sedation with ketamine. Emerg Med J 2018; 35:524-525

Krauss B, Green SM. Procedural sedation and analgesia in children. Lancet 2006;367(9512):766-80

Nickson C. Paediatric Procedural sedation with Ketamine. Life in the Fast Lane. March 2019

Zier ZL, Liu M. Safety of high concentration nitrous oxide by nasal mask for pediatric procedural sedation: experience with 7802 cases. Pediatr Emerg Care. 2011 Dec;27(12):1107-12

Gamis AS, Knapp JF, Glenski JA. Nitrous oxide analgesia in a pediatric emergency department. Ann Emerg Med. 1989; 18:177-181

Comfort Kids Programme. Royal Children’s Hospital Melbourne. 2016

Peyton PJ, Wu CY. Nitrous oxide-related postoperative nausea and vomiting depends on duration of exposure. Anesthesiology. 2014;120(5):1137–1145

Baum VC. When nitrous oxide is no laughing matter: nitrous oxide and pediatric anesthesia. Paediatric Anaesthesia 2007;17(9):824-30

Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine. Acute Pain Management: Scientific Evidence.: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2005

Axelsson G, Ahlborg G, Jr., Bodin L. Shift work, nitrous oxide exposure, and spontaneous abortion among Swedish midwives. Occupational & Environmental Medicine 1996;53(6):374-8

Hoeffe J et al. Intranasal fentanyl and inhaled nitrous oxide for fracture reduction: The FAN observational study. Am J Emerg Med. 2017;35(5):710-715.

Seith RW, Theophilos T, Bable FE. Intranasal fentanyl and high-concentration inhaled nitrous oxide for procedural sedation: a prospective observational pilot study of adverse events and depth of sedation. Acad Emerg Med. 2012;19(1):31-6

Kennedy RM, Porter FL, Miller JP, Jaffe DM. Comparison of fentanyl/midazolam with ketamine/midazolam for pediatric orthopedic emergencies. Pediatrics. 1998;102:956–63

Pena, B.M. and Krauss, B. Adverse events of procedural sedation and analgesia in a pediatric emergency department. Ann Emerg Med. 1999; 34: 483–491

Wright, S.W., Chudnofsky, C.R., Dronen, S.C. et al. Midazolam use in the emergency department. Am J Emerg Med. 1990; 8: 97–100

Davies FC, Waters M. Oral midazolam for conscious sedation of children during minor procedures. J Accid Emerg Med. 1998;15(4):244–248. doi:10.1136/emj.15.4.244

Graff, K.J., Kennedy, R.M., and Jaffe, D.M. Conscious sedation for pediatric orthopaedic emergencies. Pediatric Emerg Care. 1996; 12: 31–35

Bailey, P.L., Pace, N.L., Ashburn, M.A. et al. Frequent hypoxemia and apnea after sedation with midazolam and fentanyl. Anesthesiology. 1990; 73: 826–830

Gregory GA. Pediatric Anesthesia. 4th ed. Philadelphia, PA: Churchill Living- stone; 2002

 

Taking your trauma team to the next level: Anna Dobbie at DFTB19

Cite this article as:
Team DFTB. Taking your trauma team to the next level: Anna Dobbie at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22066

Anna Dobbie works in HEMS, PEM, and Adult ED and is a badass at all of them. She is the person you’d want leading your trauma team. Want to be just a little more like Anna? Then watch her talk and find out how to step up.

As we are so fond of saying, “You set the tone.” That first two minutes of any resus is critical – and not just because of the decisions you make. If you can appear calm and in control, your teams’ actions will reflect that. Running every trauma call the same allows for cognitive off-loading as some behaviours become automatic. Whether they are ‘real’ calls or not so serious ones the team is expected to act the same either way.

 

 
 
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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Orbital fractures

Cite this article as:
Orla Kelly. Orbital fractures, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.21843

Epidemiology

Facial fractures in children accounted for just 4.6% of paediatric trauma admissions on review of the American National Trauma Databank. However, even though they are less prevalent than in an adult population, they are associated with other severe injuries and higher mortality compared with adults. The pattern of injury descends the face as the patient ages – the under 5s are more likely to sustain frontal bone and orbital roof fractures, while the 6-16-year-olds are more likely to have midface and mandibular fractures. Orbital fractures as a subset comprise between 5 to 25% of facial fractures.

Anatomy

Bones of the orbit
  • The orbit is comprised of 7 bones – maxilla, zygomatic, frontal, ethmoid, lacrimal, sphenoid and palatine.
  • The rim is formed by the frontal bone, maxilla, and zygoma.
  • The orbits are pyramidal structures, with a wide base opening on the face, with its apex extending posteromedially.
  • They lie anterior to the middle cranial fossa and inferior to the anterior cranial fossa.
  • Their close proximity to the sinuses coupled with the ophthalmic veins communicating with the cavernous sinus creates a possible introduction of infection into the intracranial cavity.
Location of the facial sinuses
  • The infra-orbital nerve exits through the inferior orbital foramen inferior to the orbital rim and innervates lateral aspect of the external nose, inferior eyelid and cheek and upper lip and related oral mucosa.
  • Paediatric anatomy and development confer different injuries depending on age, with orbital floor fractures becoming more common than roof fractures at approximately age 7 due to the development of the maxillary sinus.

History and Examination

Mechanism of injury is always important to elicit in trauma as well as careful and thorough (and documented) examination. Initial assessment as always in trauma is by the ATLS ABC approach followed by a careful secondary survey.

Children are prone to a pronounced oculocardiac reflex which may become apparent in the initial ABC assessment; this is caused by compression of the globe or traction on the extra-ocular muscles. Connections between the sensory afferent fibres of the ophthalmic division of the trigeminal nerve and visceral motor nucleus of the vagus nerve cause bradycardia and hypotension often with headache, nausea, and vomiting.

Have a systematic approach to examination so as to ensure all important aspects are covered. Always examine and document:

  • General inspection – oedema, laceration, and bruising
  • Enophthalmos/proptosis
  • Subconjunctival haemorrhage
  • Periorbital emphysema
  • Pupillary response including RAPD
  • Eye movements in all directions
  • Visual acuity
  • Diplopia
  • Palpation of the orbital rim for tenderness or step
  • Abnormalities of the nasal bridge (saddle nose deformity) and widening of the midface (telecanthus)
  • Disruption to the infraorbital nerve: numbness of the ipsilateral cheek, lip, and upper gum
Sensory distribution of infra-orbital nerve

Investigation and Management

Investigation of orbital fractures is by x-ray and CT, with CT being the modality of choice, though it can be unreliable in children with blowout fractures. A CT may already be appropriate due to a mechanism of injury or red flags for a head injury.

The aim of initial management in the ED is to prevent further damage to the globe.

Patients should be advised to not blow their nose and to sneeze with their mouths open. A cold compress and raising the head of the bed can help alleviate periorbital oedema. Ensure the eyelids can close fully and lubricate the cornea. Provide a protective patch if necessary.

 

Types of Injuries

 Orbital Floor and Medial Orbital Wall Fractures

The term ‘blow out fracture’ has historically meant a fracture of the orbital floor secondary to a direct blow to the globe, causing an increase in pressure that results in the thin orbital floor fracturing. Children presenting with floor or medial wall fractures are at high risk of entrapment, as paediatric bones are more prone to greenstick fracture, which then creates a ‘trapdoor’ effect ensnaring the inferior oblique and inferior rectus muscles or other orbital contents. Clinically, the child will be unable to complete upwards gaze. Entrapment is a surgical emergency, as ischaemia of the involved musculature can cause permanent damage. The infraorbital nerve is commonly damaged in these injuries.

Orbital blow out fracture

Children with orbital floor fractures may not have any facial bruising, classically presenting with a ‘white-eyed’ fracture with the only sign being limitation of eye movement secondary to entrapment.

(A) Restriction of upgaze in the right eye with no evidence of periocular trauma. (B) CT scan of the orbits demonstrating inferior rectus muscle entrapped within inferior orbital wall fracture (arrow). Reproduced with permission from www.emj.bmj.com

Orbital Roof Fractures

Orbital roof fractures are more common in childhood as the frontal sinus has not yet pneumatised, therefore all posterior force to the superior orbital rim is transferred to the anterior cranial base. Another mechanism of injury is a ‘blow-in’ fracture, where there is an inferiorly directed supraorbital force.

NOE (nasal-orbital-ethmoidal) Fractures

Nasal bone injuries are common in older children and adults and must always be assessed for an underlying NOE fracture. When direct force is applied to the nasal bone, it can cause a collapse of the paired nasal, lacrimal, and ethmoidal bones. If this fracture is missed in a child, significant midface deformities can result.

Midfacial fractures

Although children are more likely than adults to suffer isolated orbital rim fractures, orbital fractures are often involved in midfacial fractures of the maxilla and zygoma: the orbit is involved in Le Fort II and III; zygoma fractures are often accompanied by orbital floor or medial wall fractures.

Globe Injuries

Orbital fractures can often result in globe injuries ranging from corneal abrasion to rupture. If there are any signs of globe rupture (360 degrees conjunctival haemorrhage, misshapen pupil or a flat anterior chamber) a gross visual examination should be completed, vaulted eye protection applied, and immediate ophthalmology consult sought. Do not apply pressure to a possibly ruptured globe.

Retrobulbar haemorrhage

A rare but sight-threatening complication is a retrobulbar haemorrhage which causes increased pressure, stretching of the optic nerve and can result in permanent blindness. If optic pressure is low, medical management with mannitol, steroids, and acetazolamide can be used after expert involvement. However, if there is an indication that the pressure is high, a lateral canthotomy should be performed as a matter of urgency. The procedure should ideally be performed by an ophthalmologist, but when ophthalmology are delayed or unavailable, the procedure must be performed by an emergency clinician in the ED. Do not delay a lateral canthotomy for imaging if sight is threatened.

Indications for lateral canthotomy include:

  • Retrobulbar haematoma
  • Decreased visual acuity
  • Afferent pupillary defect
  • Proptosis

Pearls

  • Repeat a child’s eye examination while they are in the emergency – repeated examination can drastically change disposition from maxillofacial non-urgent transfer to a blue light ophthalmological review
  • Oculo-cardiac reflex can cause bradycardia and hypotension
  • Children are more likely to have other and significant injuries: the secondary and tertiary survey is imperative.
  • Children are more likely to suffer ‘trapdoor’ floor fractures causing entrapment that can present as a ‘white eye’ fracture– this is a surgical emergency, act fast.
  • Patients should avoid nose blowing and should sneeze with their mouth open following injury.
  • Ophthalmological assessment should be sought in all patients with orbital trauma.

Selected references

Imahara SD, Hopper RA, Wang J, Rivara FP, Klein MB. Patterns and outcomes of pediatric facial fractures in the United States: a survey of the National Trauma Data Bank. J Am Coll Surg. 2008;207:710–716

Oppenheimer AJ, Monson LA, Buchman SR. Pediatric orbital fractures. Craniomaxillofac Trauma Reconstr. 2013;6(1):9–20.

Koltai PJ, Amjad I, Meyer D, Feustel PJ. Orbital fractures in children. Arch Otolaryngol Head Neck Surg. 1995;121:1375–1379

Cohen SM, Garrett CG. Pediatric orbital floor fractures: nausea/ vomiting as signs of entrapment. Otolaryngol Head Neck Surg. 2003;129:43–47

Grant JH III, Patrinely JR, Weiss AH, Kierney PC, Gruss JS. Trapdoor fracture of the orbit in a pediatric population. Plast Reconstr Surg. 2002;109:482–489; discussion 490–495

Boyette, J. R., Pemberton, J. D., & Bonilla-Velez, J. (2015). Management of orbital fractures: challenges and solutions. Clinical ophthalmology. 2015;9:2127–2137.

Cobb ARM, Jeelani NO, Ayliffe PR. Orbital fractures in children. British Journal of Oral and Maxillofacial Surgery. 2013;41–46

Kassam K, Rahim I, Mills C. Paediatric orbital fractures: the importance of regular thorough eye assessment and appropriate referral. Case Rep Emerg Med. 2013:376564. doi:10.1155/2013/376564

Surviving Sepsis Campaign International Guidelines

Cite this article as:
Damian Roland. Surviving Sepsis Campaign International Guidelines, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.23460

The lens with which you view sepsis is dependent on the environment and emotion in which you associate the term. For a parent, this may be the spectrum from having never heard the term before “Your child is well enough to go home, we’ve ruled out sepsis and other serious conditions” to the anguish of being told, “I’m afraid your child died of sepsis“. This spectrum remains equally wide for health care professionals. A family doctor or general practitioner may never see a case of confirmed sepsis, and an emergency clinician can potentially go years between seeing a truly shocked child. An intensivist, however, may deal with the consequences on a weekly basis. Even in the last month, we have seen two papers from the same publishing group; one highlighting the global burden of sepsis and the other challenging the current hype surrounding its recognition and management.

Regardless of your viewpoint, the publication of the Surviving Sepsis campaign’s international guidance will have been of interest.

 

Weiss, S.L., Peters, M.J., Alhazzani, W. et al. Surviving sepsis campaign international guidelines for the management of septic shock and sepsis-associated organ dysfunction in children. Intensive Care Med 46, 10–67 (2020). https://doi.org/10.1007/s00134-019-05878-6

 

It is important to recognize two features of this publication which should carry an important health warning in its interpretation.

The first is that the authors are clear that they are focusing on severe sepsis or septic shock. While in adult practice definitions have changed, these have not been formalized or ratified for children:

 

“For the purposes of these guidelines, we define septic shock in children as severe infection leading to cardiovascular dysfunction (including hypotension, need for treatment with a vasoactive medication, or impaired perfusion) and “sepsis-associated organ dysfunction” in children as severe infection leading to cardiovascular and/or non-cardiovascular organ dysfunction.”

 

The authors clearly recognize that the absence of a clear definition of paediatric sepsis is challenging health care providers and organizations. The group has steered away from suggesting management options in the ‘pre-sepsis’ group i.e. those children with potential infections that may result in sepsis and have physiological instability but without organ dysfunction. They suggest that management practices for this group aren’t radically different, however:

 

Even though these guidelines are not intended to address the management of infection with or without SIRS when there is not associated acute organ dysfunction, we recognize that sepsis exists as a spectrum and some children without known acute organ dysfunction may still benefit from similar therapies as those with known organ dysfunction

 

The second is that this is a consensus document. It is neither a systematic review nor a clinical practice guideline (in a local hospital sense). It comprises the opinions of an expert group of clinicians (49 in fact) from a variety of international settings using the best available evidence. The publication is essentially a list of recommendations. This approach is valid in situations where evidence may be heterogeneous and that randomized controlled trials can not be performed for all possible permutations of clinical practice. As with all things in science, however robust the data is, it still needs interpreting and that interpretation is subject to all manner of explicit and implicit bias.

 

The panel supports that these guidelines should constitute a general scheme of “best practice,” but that translation to treatment algorithms or bundles and standards of care will need to account for variation in the availability of local healthcare resources.

 

Without becoming meta it’s important that this blog itself needs a health warning. It’s an interpretation of an interpretation of evidence.

So the big-ticket items

1. A child was defined as beyond 37 weeks gestation and up to 18 years old.

2. They apply to children with severe sepsis or septic shock as defined by the 2005 International Pediatric Sepsis Consensus Conference or inclusive of severe infection leading to life-threatening organ dysfunction.

2005 definition:

  • greater than or equal to two age-based systemic inflammatory response syndrome (SIRS) criteria
  • confirmed or suspected invasive infection, and cardiovascular dysfunction
  • acute respiratory distress syndrome (ARDS), or greater than or equal to two non-cardiovascular organ system dysfunctions

Septic shock was defined as the subset with cardiovascular dysfunction, which included hypotension, treatment with a vasoactive medication, or impaired perfusion.

3. Panel members were selected through recommendations from chairs and vice-chairs of the 12 worldwide member organizations. Each panel member was required to be a practicing healthcare professional with a focus on the acute and/or emergent care of critically ill children with septic shock or other sepsis-associated acute organ dysfunction. There was lay representation and the final membership was felt to be demographically diverse with regard to sex, race, and geography.

4. The panel was assisted by various methodological experts and split into six groups

  • recognition and management of infection
  • hemodynamics and resuscitation
  • ventilation
  • endocrine and metabolic therapies
  • adjunctive therapies
  • review research priorities in pediatric sepsis

5. A list of critical questions was developed in the PICO format (Population, Intervention, Control, and Outcome) which was then rigorously searched for by a specialist medical librarian and the resulting literature assessed according to GRADE criteria a well-recognized methodology for systemically presenting summaries of evidence.

6. Following discussion and debate recommendations would be made:

 

We classified recommendations as strong or weak using the language “We recommend…” or “We suggest…” respectively. We judged a strong recommendation in favor of an intervention to have desirable effects of adherence that will clearly outweigh the undesirable effects. We judged a weak recommendation in favor of an intervention to have desirable consequences of adherence that will probably outweigh the undesirable consequences, but confidence is diminished either because the quality of evidence was low or the benefits and risks were closely balanced.

 

The paper goes into considerable detail (which is why it is 55 pages long) into the rationale behind the recommendations. They are all summarised in the appendix (commencing page e102). It is beyond the scope of this blog to explore all the recommendations in detail, and it is important that health care providers read the paper itself. The following highlights some of the areas which may prompt debate or query.

 

‘Screening’ remains in

For those in emergency and acute care, this recommendation may have come as a surprise given a large amount of anecdotal feedback and experience suggesting that current screening mechanisms for the un-differentiated child are neither specific nor sensitive. It is worth nothing again the panel was looking at severe sepsis or shock and the evidence for ‘bundles’ of care i.e. targeted or mandated treatments once recognized is relatively robust. There is a further section on protocols/guidelines for treatment but it may have been useful to separate the afferent limb (recognition) from the efferent limb (response) in relation to collated evidence. This is important as the evidence for ‘bundles’ is cited under screening, with minimal evidence of screening approaches alone put forward (or to be fair to the panel perhaps of insufficient quality to make a judgment on).

Although subtle I think the panel recognized how important local buy-in is in relation to quality improvement. Of note, there is nothing on national guidance for recognizing sepsis. They also highlight how blindly integrating screening with any other scoring system may not be as beneficial as believed.

Ultimately no one particular screening system is recommended.

 

There is no target lactate

There appears to be a palpable sense of regret that the evidence didn’t support any particular threshold for lactate. Despite evidence of rising mortality with increasing lactate, the panel was not able to determine a specific level.

However, no RCTs have tested whether initial or serial measurement of blood lactate directly informs evaluation and/or management in children. Lactate levels should, therefore, be interpreted as a part of a more comprehensive assessment of clinical status and perfusion.

 

Take blood cultures but don’t delay treatment to obtain them

Appreciating this isn’t a particularly scientific response, but well, duh.

 

One hour time to treatment for those in shock but up to three hours without it. 

This is the potential game-changer from this body of work. While the evidence shows a temporal relationship between the administration of antibiotics and outcome in severe sepsis some pooled data demonstrated that it was unlikely the hour alone made the difference. Given the numerous papers showing a linear relationship between time to administration and outcome the ‘golden hour” was maintained. In the absence of shock, the panel felt, based on data showing a three-hour threshold effect, this would be a reasonable time point. This will be a welcome relief for those working in areas where there are associated penalties for not reaching the hour window and hopefully will remove some of the gaming associated with this target.

 

Broad spectrums antibiotics, but narrow when pathogens available

Little controversy here. The panel highlight that 48 hours should be the maximum time that is allowed to pass before re-evaluation in the absence of culture growth rather than a standard time to elapse.

If no pathogen is identified, we recommend narrowing or stopping empiric antimicrobial therapy according to clinical presentation, site of infection, host risk factors, and adequacy of clinical improvement in discussion with infectious disease and/or microbiological expert advice.

There are a number of recommendations on immunocompromised children and source control which appear pragmatic.

 

Bolus if intensive care available, if not then don’t unless documented hypotension

In units with access to intensive care, 40-60ml/kg bolus fluid (10-20ml/kg per bolus) over the first hour is recommended. With no intensive care, and in the absence of hypotension, then avoiding bolus and just commencing maintenance is recommended. It is not clear how long access to intensive care has to be to switch from fluid liberal to restrictive.

**Post-publication note (13/02/20): A more correct description of no intensive care would be “in health systems with no access to intensive care”. The guidance states, “For children with septic shock without signs of fluid overload in low-resource settings where advanced supportive and intensive care is not available, the panel recommends against bolus fluid administration,”. This question is raised in the comments section below as for units in without intensive care on site but it will resourced health systems then ‘access’ to intensive care should be assumed**

For purposes of this weak recommendation, hypotension can be defined as:

 

The panel suggests crystalloids, rather than albumin, and balanced/buffered crystalloids rather than 0.9% saline. They recommend against using starches or gelatin.

 

Use advanced haemodynamic variables, not bedside clinical signs in isolation

The evidence didn’t support a target mean arterial blood pressure but suggested avoiding using clinical signs to differentiate into cold and warm shock. No one monitoring approach was advised but included cardiac output, cardiac index, systemic vascular resistance, and central venous oxygen saturation.

 

Intensive care vasoactive and ventilation management is given but acknowledged as weak recommendations 

There is a list of suggestions regarding vasoactive infusion and ventilatory strategies that are very specific to intensive care management. While a number of recommendations are given (epinephrine rather than dopamine for septic shock for example) these are generally based on the panels summation of weak evidence.

There are further suggestions on corticosteroid management, nutrition, and blood products which will be of interest to those in intensive care and anaesthetic settings.

 

Summary

This is a very rich piece of work that is well structured and easy to read (even if you are not an expert on a particular field of practice). For most paediatricians there is unlikely to be an immediate change in practice but the softening of antibiotic time to delivery in the non-shocked child and emphasis of local review of sepsis incidence and performance will be welcome. How these filter into national guidance will be determined country by country but it is unlikely that radically different views can be drawn from the available evidence. What is still sorely needed is a working definition for the non-hypotensive child with sepsis (or an acknowledgment that perhaps this isn’t really a clinical entity…)

 

All Things Patella

Cite this article as:
Tadgh Moriarty. All Things Patella, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22204

Patella dislocation

Robert is a 14-year-old boy who has just arrived by ambulance having been playing a rugby match. He was running just short of the try line when he tried to make a dastardly last-minute course correction, however, while rapidly altering course his body went one way, while his foot remained planted on the ground and he felt his left knee suddenly give way. A sudden surge of pain followed and he dropped to the ground. On the ambulance stretcher, you see his knee is hugely swollen with an obvious deformity out laterally. He is in obvious pain and distress. The triage nurse thinks his patella is dislocated and wants you to prescribe some analgesia.     

Incidence

Patella dislocation is a common knee injury, particularly associated with sports (61-72% Steiner 2010) and physical activity among teenagers.

 

Mechanism

The two most common mechanisms for a patellar dislocation are:

  • Non-contact twisting injury (66-82% Khormaee 2015) – this is where foot remains planted on the ground, usually externally rotated, while the knee is extended and internal rotation about the hip causes a dislocation.
  • Direct contact (less common) – e.g. knee to knee strike during basketball or a helmet/head to knee in rugby.

 

Risk factors

Some children are more prone to patellar dislocation than others. It is worth noting that those with underlying anatomical abnormality may not present with as much obvious swelling and deformity as those with normal anatomy. Look out for the following:

  • Connective tissue disorders e.g. Ehlers-Danlos
  • Lateral patellar tilt
  • Trochlear dysplasia
  • Genu valgum (‘knock-knee’)
  • Patella alta (high-riding patella)
  • Increased femoral anteversion
  • Vastus medialis muscle hypoplasia

 

Presentation

A child will usually present following a sudden ‘pop’ or sensation of instability and severe anterior knee pain. Acute dislocation is usually associated with a moderate haemarthrosis, however, those with underlying risk factors (especially ligament hyperlaxity) may not.

A detailed ligamentous exam is important to assess for integrity and damage to cruciate and collateral ligaments. Medial tenderness is common as the MPFL (medial patella-femoral ligament) is ruptured in over 94% of dislocations. Providing over half of the restraining force for the patella, it extends to its medial border from the femur.

The patellar apprehension test is described for those whose dislocations have reduced pre-hospital (according to Willis et al. most spontaneously reduce). With the knee flexed to 30 degrees, apply some lateral pressure; with medial instability, the patient will feel apprehensive about the kneecap “popping” again.

 

Treatment

This is a painful injury so ensure adequate analgesia has been provided. Next question – has the dislocation been reduced yet? If yes – jump to post-reduction management, if not read on…

The use of procedural sedation with nitrous oxide is ideal for this short painful procedure. Flex the hip on the affected side, thereby relaxing the quads muscle. Apply pressure to the lateral border of the patella in a medial direction while extending the knee. A satisfying ‘clunk’ should be felt as the patella slides back into its home in the trochlear groove of the distal femur.

 

Post-reduction management:

There is no evidence-based consensus to guide ongoing treatment, especially in first-time dislocations (see controversies below). Once reduced, the application of a knee immobilizer will help reduce ongoing analgesia requirements. Studies have failed to demonstrate a benefit of one type of immobilization device over another – therefore follow local guidance; knee brace in full extension, cylinder cast or above knee back-slab are all acceptable.

Ensure ongoing analgesia requirements post-discharge are met, and consider crutches until seen back in the orthopaedic clinic.

 

Imaging

This is not always necessarily required pre-reduction. A post-reduction x-ray (AP and lateral) is important to assess associated osteochondral fractures and to check the patella location. An MRI scan can be particularly useful to assess for associated ligamentous integrity and rupture, VMO sprain, and osteochondral fractures. In fact, MRI is more sensitive than arthroscopy to assess for MPFL tear. However, this can be organized from orthopaedic follow-up clinic.

 

What to tell the patient

Will it happen again?

The younger the patient the higher the rate of re-dislocation: 60% for those 11-14 years, and 33% 15-18 years.

Is everything fixed now that the kneecap is back in place?

It can be difficult to tell is there are associated ligamentous injuries on the day of presentation which can lengthen recovery to baseline. Not all osteochondral fractures will be apparent on the plain film radiograph. Repeat examination in the orthopaedic clinic +/- MRI will often provide a more detailed assessment of prognosis.

What happens next?

Traditionally first-time dislocations were treated with immobilization for 3-6 weeks followed by intensive physio to strengthen the quads. There is now a move towards earlier motion and rehab (despite a lack of RCTs). Surgery has usually been reserved for those requiring loose body (within the joint) removal, fixation of osteochondral fractures and for those with recurrent instability and dislocation.

When can I go back to playing sports?

As a general rule of thumb 8-12 weeks.

 

Controversies

There has been a recent trend towards surgical fixation (usually of the MPFL) in recent times. Whereas this was usually reserved for recurrent dislocations, a systematic review by Nwachukwu et al in 2015 showed reduced re-dislocation with surgical treatment of first time patellar dislocation (31% Vs 21%, p=0.04). However, there was no difference between surgery versus conservative management in subjective or objective knee function.

Why is this important? Ultimately it will depend on local orthopaedic preference but it’s important to know that not all first-time dislocations will be treated conservatively so we don’t inadvertently give parents and patients misinformation.

 

Case Resolution

You correctly identify this as a patellar dislocation and organize a nitrous oxide procedural sedation and successfully reduce the dislocation. Post-procedure you place his knee in an above-knee backslab and organize a fracture clinic follow up. Before leaving you to ensure his parents have appropriate dosed analgesia at home.

 

Patellar tendon rupture

Rachel is a 13-year-old girl who is a keen runner and has recently discovered a passion for hurdling. She was attending training, on her third lap, while jumping over the hurdle felt a sudden pop followed by immense pain causing her to drop to the ground. She was unable to walk, the pain being too intense. An ambulance was called and the triage nurse asks you to see her next as she is crying in pain.

 Incidence

This is a relatively rare condition with the peak age of occurrence being 40. That being said, the rate of patella tendon rupture (PTR) is increasing in frequency. This is often a sports-related injury (e.g. hurdling, basketball) with the mean age for children being 13 years.

 

Mechanism

The patellar tendon is part of the very important extensor mechanism of the knee, connecting the patella to the tibial tuberosity. This is crucial to help us overcome the forces of gravity. The entire mechanism includes the quads femoris muscles, the quads tendon, the patellar tendon, the patella itself and the tibial tubercle.

The most common ways to injure the PTR is through a direct blow (e.g. fall), or through forceful contraction of the quads muscle (usually while the foot is planted and knee flexed) – e.g. missing a step while climbing stairs, or in jumping sports.

The force required to rupture the tendon is 17 times that of the average body weight

There are three main patterns of injury which can result

  • Avulsion from the inferior pole of the patella (there is an increased risk of concurrent bony avulsion with children’s growth plates)
  • Mid-tendon
  • Distal avulsion from the tibial tuberosity

 

Risk factors

Conditions that cause microscopic damage to the tendon blood supply such as repeated microtrauma (e.g. athletes), chronic renal failure, collagen vascular disease, diabetes, osteogenesis imperfecta, and steroid use.

 

Presentation

There will usually be some history of a popping sensation, knee pain, swelling and difficulty or inability to weight bear. On exam, the knee usually has a moderately large haemarthrosis. A high riding patella (patella alta) may be noted when compared to the contralateral side.  Localized tenderness and a palpable gap below the inferior pole of the patella may be present in complete tears. The pain will limit the range of movement of the knee. The inability to actively straight leg raise is indicative of serious extensor mechanism pathology and should be assumed to be a complete tear until proven otherwise. Pain may limit the range of movement examination of the knee (ensure adequate analgesia) so an alternative is to have the patient maintain a passively extended knee.

 

Imaging

X-rays – AP and lateral. While not conclusive, certain features may suggest the diagnosis. A joint effusion is likely, the presence of a high riding patella (patella alta) is highly suggestive of a complete tear.

 

Want to really impress your orthopod service – measure the Insall-Salvati ratio and if >1.2 – this is diagnostic of patella alta. This is measured by A/B, where A= patellar tendon length (posterior surface of the tendon from the lower pole of the patella to tibial insertion) and B = patellar length (longest pole -> pole length).

Ultrasound – while this modality is user and operator dependent, its availability aids its usefulness. It can be effective at detecting and localizing disruption to the tendon. Differentiating between partial and complete tears can be more challenging.

 

MRI – the favoured imaging modality, but access can limit its usefulness. It will aid accuracy in delineating partial from complete tears and reveal any associated bony avulsion or soft tissue injuries.

 

Treatment

Consider the diagnosis. While a rare event among the paediatric population, delayed diagnosis causes increased morbidity. 7% of those who sustain acute trauma to the knee will have a PTR. These are painful injuries, and so judicious use of analgesia is paramount.

 

Conservative management may be considered for those children with only partial tears and an intact extensor mechanism. Immobilization with a removable knee splint in full extension followed by graduated weight-bearing and rehab program.

 

Surgical repair is indicated for complete tears. A comparison of different techniques is difficult due to the small numbers of patients. Two main options exist depending on the level of the tear, associated injuries and surgeons choice:

  • Primary repair – using end to end repair, trans-osseous repair or suture anchor tendon repair.
  • Tendon reconstruction is usually reserved for severely disrupted tendons and involves the use of an autograft.

 

Controversies

Traditional management post-surgery involved applying a cylinder cast for six weeks allowing the child to weight bear as tolerated. A newer school of thought involved early controlled movement at the joint. This involves applying a knee brace which allows up to 90 degrees of flexion for four weeks followed by graduated controlled increases in flexion until 12 weeks. This early mobilization aids quicker knee function return and prevents muscle atrophy.

 

What to tell the patient

Will I need an operation?

If there is complete tendon rupture or a compromised extensor mechanism, then surgical repair is needed.

When can I return to sports?

Full return to sports usually takes six months (range of 13-30 weeks depending on exact injury).

 

Case Resolution

On examination, you note she Rachel is unable to straight leg raise. An x-ray shows a large haemarthrosis. You refer her to the on-call orthopaedic service and the next day she undergoes an MRI confirming your suspicions of a patellar tendon rupture. This is operatively repaired and she has now commenced her rehab, looking forward to returning to running soon.

 

Patella fracture

The next card you pick up is a 14-year-old boy (Brian) who is a ‘return’ patient. He attended two days ago with right knee trauma and has represented with ‘ongoing pain’. He was playing rugby at the time and made a sudden twisting movement while avoiding a tackle. He felt searing hot pain in his knee and dropped to the ground. He wasn’t able to walk and had to be stretchered off the pitch. He had intranasal fentanyl pre-hospital and a top-up dose in triage two days ago. Being a keen sports player and with the rugby final coming up he was determined to return to play and was documented in the notes as being able to ‘tentatively weight bear’. On exam, you note a tense, swollen right knee. Being stoic he denies any focal tenderness but you notice a grimace when you examine his inferior patella. He is unable to straight leg raise and when he attempts to weight bear fully he is clearly in pain. You wonder whether his patellar tendon might be injured as surely a fracture would have been noted on his XR from two days ago….

Incidence

Patellar fractures are relatively rare, with an incidence of 0.5-1.5% of all skeletal injuries. They are most common between 8-16 years with a mean age of 12.4 years. Unsurprisingly they are mainly caused during sporting and leisure activities.

 

Mechanism

There are two main types of patellar fractures in paediatrics. The first is a ‘typical’ bony fracture, which is caused by a direct impact on the patella, similar to adults. The second is almost exclusive to paediatrics; patellar sleeve fracture. These are caused by indirect trauma to the knee and are the result of a forceful quads muscle contraction in a skeletally immature individual. Patellar sleeve fractures are three times more common in males than in females. They account for over 50% of all patellar fractures in children. Inferior pole sleeve fractures are most common.

 

Presentation

There may be a history of either a direct blow to the knee or a non-contact twisting injury with the foot planted. A knee effusion is likely to be present, with point tenderness at the affected site. Inability to extend the knee fully and inability to fully weight bear are red flags and underlying pathology must be assumed. Patella alta or patella baja may be present with patellar sleeve fractures with disruption of the inferior (alta) or superior (baja) tendon. A palpable gap may be present inferior/superior to the patella with complete disruption of the corresponding tendon.

 

Imaging

X-ray: AP and lateral radiographs. A haemarthrosis may be visible. Bony fractures of the patella are most likely to be transverse or vertical. The patellar sleeve fractures require a high index of suspicion and can easily be missed as often only a tiny sliver of avulsed bone can be seen on plain film. Don’t be misled by this seemingly innocuous x-ray finding, a significant cartilaginous component will be involved.

Image from Orthobullets: Patellar sleeve fracture

Up to 8% of the population have bipartite patella – don’t confuse this for a patella fracture. Contralateral imaging is not always useful as 50% of those affected will have bilateral patella affected. Characteristically it will be present supero-laterally and will have smooth edges around the cortex.

Courtesy of Orthobullets: X-Ray showing bipartite patella

Ultrasound: can be helpful in confirming injury to the tendon. Soft tissue oedema and fluid hyperemia are other indirect signs that may be seen suggestive of tendon disruption.

 

MRI: this remains the imaging modality of choice if the diagnosis is in doubt. This will allow displaying the extent of the chondral injury and any concomitant extensor mechanism injury.

Treatment

Non-operative: this may be considered in those with a nondisplaced (<2mm) fracture and an intact extensor mechanism. A cylinder cast will be applied for six weeks and then intensive rehab following its removal.

 

Operative: Any displaced fracture (>2mm) usually require open reduction and internal fixation (as the extensor mechanism needs to be restored).

Patella sleeve fractures will require ORIF with suturing of the tendon; superior sleeve fracture necessitating quads tendon repair, and inferior sleeve fracture requiring patellar tendon repair.

Post-operatively these patients are usually placed in an extension brace or cast until the wound is healed and then active flexion and extension exercises are commenced to restore normal knee function as soon as possible.

 

What to tell the patient?

Is there a fracture there?

If no fracture can be seen but the child has a large swollen knee, cannot weight bear or cannot fully extend the knee – have a low threshold to immobilize the knee even in the absence of a fracture on plain film. Patellar sleeve fractures are easily missed and lead to increased morbidity for the patient. If ready access to ultrasound or MRI this will confirm or refute the diagnosis, otherwise immobilize the knee and arrange confirmatory imaging as soon as possible or via local orthopaedic outpatients.

When can I return to sport?

Depending on the fracture and associated tendon injury – usually 3-6 months.

 

Case resolution

On review of his x-ray from two days previously you notice a tiny sliver of bone inferior to the patella and you organize an ultrasound which confirms your suspicions of a patellar sleeve fracture, involving his patella tendon. You apologize to his parents for the delayed diagnosis and refer him to the on-call orthopaedic service for an ORIF.

 

 

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