Don’t Forget The Brain Busters – Round 2 answers

And here are the answers to the Bubble Wrap Treasure Hunt Round

Question 1

In Freedman et al.’s study of the management of gastroenteritis, apple juice was found to have fewer treatment failures than electrolyte maintenance solution. But how many of the recruited 647 children actually had evidence of dehydration?

And the answer is… B: 206 (31.8%)

Freedman et al (2016) investigated children aged 6 to 60 months with minimal dehydration presenting with mild gastroenteritis (defined as diarrhoea or vomiting in the preceding 24 hours, with less than a 96-hour history). They compared half-strength apple juice to a standard apple-flavoured oral electrolyte solution and found that children who were given dilute apple juice followed by their preferred fluids were less likely to be hospitalized, given iv fluids, reattend with the same illness or have a worsening clinical dehydration score within 7 days.

The catch, as alluded to in the question, is that only 31.8% of the children recruited into the trial had any clinical evidence of dehydration. So, sure, use diluted apple juice for very mildly dehydrated children presenting to your ED with gastroenteritis but keep a stock of oral rehydration solution handy!

Learning resources: Original paper and DFTB review

Question 2

In Maitland et al.’s groundbreaking FEAST study examining different fluid regimes for the management of sepsis how many children in TOTAL (of 3141 randomised) had severe hypotension (a systolic less than 50mmHg in <12 months old, <60mmHg in 1-5 year olds, <70 mmHg in older than 5 year olds plus one or more feature of impaired perfusion)

Answer (drum roll please)… A) 6

Sparking huge controversy, 2011 saw the publication of this large RCT in East Africa of over 3000 children was terminated early when it demonstrated an increase in mortality for children given a bolus of 0.9% saline or 5% albumin. Receiving a fluid bolus was associated with a worsening of respiratory and neurological function, anaemia and metabolic acidosis. These, in turn, were associated with worsening mortality. However, the study received much criticism as many children didn’t have blood pressure measured. Various rationales have been put forward as to why the study findings are not applicable to high-resource settings.

Understanding this study is important. Read the review of the 2019 Lancet re-analysis of the data, listen our podcast of Elliot Long at DFTB18 and go back and read the original paper.

Learning resources: DFTB Summary of the Lancet review, DFTB Podcast and original paper

Question 3

In Cunningham et al.’s influential BIDS study, assessing whether the 90% or higher target for management of oxygen supplementation was equivalent to a normoxic 94% or higher target for infants admitted to hospital with viral bronchiolitis what was the primary outcome measure?

The answer isn’t length of stay but… D) Time to resolution of cough

In this very clever double-blinded RCT, Cunningham’s group randomized 615 ward-admitted infants with bronchiolitis aged 6 weeks to 12 months of age to either a standard oximeter (which showed true saturations with clinicians instructed to give oxygen if sats dropped below 94%) or a modified oximeter (which showed measured sats of 90% as 94% so oxygen was not given until sats dropped below 90%). The primary outcome was time to resolution of cough. The group found no difference in time to cough resolution between the ‘true sats’ and ‘false sats’ groups (15 days) and no significant difference between adverse events between the two groups. This landmark trial has allowed us to consider managing infants with bronchiolitis, between 6 weeks and 12 months of age, to an oxygen saturation target of 90% or higher.

Learning resources: Original paper

Question 4

In Winter et al.’s 4 year retrospective review of 33185 children how many adverse events were there in children discharged with at least one abnormal vital sign?

The answer to this one is… B) 24

In a nearly 4 year retrospective review of over 33,000 patients discharged from a Children’s ED in New York, over 5,500 (17%) had at least one abnormal vital sign. There were only 24 adverse events (0.43%) in those discharged with at least one abnormal vital sign, but this was significantly different than the 0.17% risk in those discharged with normal observations. Adverse events were defined as death, representation to hospital and admission for 5 or more days, CPR, endotracheal intubation and unexpected surgery.

Have a read of Damian’s thoughts on the paper in the 10^th bubble wrap as well as going back to the original article.

Learning resources: DFTB 10^th bubble wrap and original paper

Question 5

In Bexkens’s et al. meta-analysis of pulled elbow how many patients do you have to treat with hyperpronation for a benefit over supination-flexion to be demonstrated?

And the final answer is… B) 4

This meta-analysis was reviewed in the first ever DFTB Bubble Wrap. It looked at the effectiveness of different manoeuvers at reducing pulled elbows. They found that hyperpronation was more effective than supination-flexion, with a NNT of 4. A subsequent Cochrane review in 2017 also found that hyperpronation is more effective but with a slightly higher NNT of 6. Check out Tessa’s pulled elbow post which reviews the evidence as well as our first ever bubble wrap.

Learning resources: DFTB pulled elbow post, DFTB 1^st bubble wrap and original paper

Here’s a spoiler alert for round 3. This one will suit the injury enthusiasts out there – it’s the minor injuries picture quiz.