Head injury – the 4-hour observation clock…

Cite this article as:
Patrick Aldridge. Head injury – the 4-hour observation clock…, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.32331

You have just seen a 3 year old boy who, one hour earlier, was running along the street, fell over and hit his head. There was no loss of consciousness, no vomiting and he’s running around the Emergency Department (ED) completely unaware of ‘social distancing’ practices. On examination he’s got a small forehead abrasion but nothing else concerning. The parent was initially concerned (so came to ED) and now wants to go home.

You think this is sensible and speak to your senior who advises that you observe him for 4 hours post-injury. You think he’s got a ’trivial head injury’ with no risk factors and ask why they need to wait a further 3 hours in ED. ‘That’s what we do’ comes the reply…

Paediatric head injuries, arguably, make up a significant proportion of children attending hospital. It’s been suggested and subsequently shown  that a fair proportion could be sent home by a competent nurse at triage even during a worldwide pandemic…

PREDICT have done some wonderful work recently with their ‘Guideline for Mild to Moderate Head injuries in Children – Algorithm’ (2021) – answering questions I have often wondered myself. However, I personally feel the two most ground-breaking of all these recommendations appear to have been glossed over. This may be because they are soooo obvious, simplistic and pragmatic but that makes me love them even more…

Trivial head injuries

Children with trivial head injuries do not need to attend hospital for assessment; they can be safely managed at home’. 

  • How many children in your own experience fall (boom boom) into this category and attended for review?
  • How much money and time (the families and the health services) could be saved if these children stayed at home?

A lot’ would be the assumption for both of these questions. However, this is currently an evidence void in need of answers.

Extended observation OR discharge

It is made very clear that children who do not fall into one of the assorted risk categories have ‘no need for observation’ aka discharge home.

  • No need to stop, pass go or take up sacred ED seating until 4 hours after their medically innocuous injury (agreed, to a parent an injury may not have been innocuous but by medical head injury rules it is).
  • The child stays for no longer than it took to see and assess them. This may be a hard practice to change in many ED’s.

4 hours

How many paediatric head injuries in your own clinical practice do you or someone else say/write the immortal words “Observe 4 hours from injury’? 

Do all the children observed for 4 hours across the world require this?

How many children, that you have seen in your practice, have deteriorated?

Why does this practice exist and what is the evidence base?

Well, there is a clear consensus on who should be observed for 4 hours from injury. In the UK, the National Institute for Health and Care Excellence (NICE) Head injury: assessment and early management CG176, 2014 – – suggests children with the following require observation for at least 4 hours from the injury:

  • Loss of consciousness lasting more than 5 minutes (witnessed)
  • Abnormal drowsiness
  • Three or more discrete episodes of vomiting
  • Dangerous mechanism of injury (high-speed road traffic accident either as pedestrian, cyclist or vehicle occupant, fall from a height of greater than 3 metres, high-speed injury from a projectile or other object)
  • Amnesia (antegrade or retrograde) lasting more than 5 minutes

The latest PREDICT guideline is slightly more prescriptive (especially around age groups) and suggests those with the following risk factors need observation for up to 4 hrs…

But why 4 hours? Why not 3 hours, as someone previously suggested with wheeze?  Why observe them at all and just CT the lot? Well, at the end of the day this is all about risk stratification. A CT scan is not without risk (that small thing called radiation?) and the actual number of abnormal CT’s (ciTBI/TBI-CT) has been shown to be quite low (2.3%) in a large group (19 920) of children with head injuries.  We want to scan those children deemed ‘high risk’ who are more likely to have an abnormal scan not those deemed medium/low risk who are less likely to have an abnormal scan.

The evidence for 4 hours

What evidence is 4 hrs observation based on? Umm, not a lot. Like many practices in medicine, it’s based on consensus and pragmatism. Many institutions follow a 4 hour target for patients to be admitted or discharged from the emergency department. Children with asthma/wheeze seem to require inhalers every 3-4 hours until discharge too and there are, no doubt, countless other examples within the medical world. Four hours observation post-injury is the consensus view and currently established practice from experts with specialist knowledge in this field. It probably came about when you had to sell your kidney to the Radiologist to get a CT scan and radiation doses delivered per scan were a lot higher than present ‘modern’ machines. It was easier to just observe the child and if they deteriorated you could then more easily argue for a scan. This is my best guess but is probably not far from the mark. Could this time be shortened in these at risk groups? Probably. But trying to research this would, no doubt, be an ethical minefield.

The clock is ticking…

There are a small select group of children with head injuries who require a period of observation post-injury, as suggested by national guidelines, decision rules and clinical gestalt. I would argue many children in ED’s across the world that are observed for ‘4 hours post-injury’ do not fall into any of the categories mentioned above and the root cause for observation being clinician preference based on defensive or outdated practice. This is understandable in those who see children infrequently, but should this be accepted going forward?

In the COVID-era we are living through, I believe there will be an increased focus on reducing unnecessary hospital footfall, ED crowding and time in a potentially risky environment. One potential quality improvement project would be to look at your own institution – how many children stay ‘4 hours post-injury’ and how many really needed to…?

Predicting paediatric traumatic brain injuries

Cite this article as:
Dani Hall and Mieke Foster. Predicting paediatric traumatic brain injuries, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.30993

The biggest challenge in managing a child with a mild to moderate head injury is deciding whether to organise a CT scan or not. Balancing the risk of ionising radiation (and with it the small, but definite, risk of a future brain tumour or leukaemia) against the risk of missing a significant brain injury is mitigated to some extent by using a clinical decision rule, like the PECARN, CATCH or CHALICE rules. These rules are extremely sensitive with very few false negatives and excellent negative prediction values, meaning if you follow them, you’re unlikely to miss a clinically important brain injury (cTBI). Their problem is their specificity is low with plenty of false positives, meaning most of the children who have a scan won’t actually have a brain injury. (If you’d like a refresher on sensitivity, specificity, NPV and PPV in head injury decision rules, check out Damian’s critical appraisal talks in DFTB Essentials.)

Over the last 6 years, Australasia’s PREDICT network has been a publishing powerhouse on paediatric head injuries from their Australasian Paediatric Head Injury Research Study (APHIRST for short). In their cohort of 20,000 children the team have been able to tell us that of PECARN, CATCH and CHALICE, the PECARN rule has the highest sensitivity. They’ve also shown that planned observation leads to significantly lower CT rates, with no difference in missed cTBI. And probably most telling of all, they’ve told us  that, without using any rules, their clinicians are already very good at identifying children with a cTBI with a sensitivity almost as high as PECARN’s, but with a very low baseline CT rate.

Nonetheless, clinical decision rules do play their role. And so, when they asked their network what an ideal decision rule would tell them, their clinicians highlighted the gaps in the existing guidelines: What should we do with a child with a delayed presentation up to 72 hours after the head injury? What about a child with a bleeding disorder and a head injury? What about a child with a VP shunt and a head injury? Or an intoxicated child with a head injury? The list goes on.

And so, in true PREDICT style, they decided to develop their own guideline.

This week marks a landmark day for paediatric head injury management worldwide as PREDICT launch their guideline for mild to moderate head injuries in children. The risk criteria from the PECARN rule, the best performing prediction rule in the APHIRST study, play a central role, supported by an extensive literature search, including studies from PECARN and PREDICT on the risk associated with VP shunts and bleeding risks. PREDICT have pulled all the data into one comprehensive, evidence-based guideline for managing, what has previously been considered, some of the less clear-cut paediatric head injury presentations. Let’s explore the algorithm and run through a series of cases.

Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children – Algorithm (2021). PREDICT, Melbourne, Australia.

How was the guideline derived?

Building on the existing high-quality clinical decision rules, the PREDICT group conducted a systematic review of the literature to include more recently published evidence. To develop the new PREDICT guideline, they used a GRADE-ADOLOPMENT approach, adopting, adapting or developing new recommendations, which are labelled in the main guideline as ‘evidence-informed recommendations’, ‘consensus-based recommendations’ or ‘practice points’.

What does it say?

This guideline is here to tell us what to do with children with a mild or moderate head injury, with a GCS of 14 or 15, or a child with a GCS ≤ 13 with a normal CT scan. The ‘who to discharge, who to observe and who to scan’ part of the guideline is succinctly summarised with a two-page algorithm. Page 1 has an easy to follow flowchart, supplemented by footnotes and Appendix with modified guidance for special conditions on page 2.

Page 1
Page 2

The bottom line

What I like so much about this guideline is that it answers so many of our “what about the child with a head injury plus…?” questions. With the evidence-based recognition that senior clinicians who choose to observe rather than scan a child reduce the CT rate without increasing the number of missed cTBIs, this guideline also allows senior clinicians to make a risk assessment on a case by case basis, while remaining fluid enough to upgrade or downgrade a child’s risk if their clinical picture changes. Although designed for use in Australia and New Zealand, I can see it being immensely useful outside Australasia and am looking forward to putting its pearls of wisdom to use.

Case 1

Case 2

Case 3

Case 4

Case 5

Cases 6 and 7

Case 8

Cases 9 and 10

Case 11

Case 12

Case 13

Case 14

Case 15

References

 Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children – Algorithm (2020). PREDICT, Melbourne, Australia.

Babl FE et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. 2017. 389;10087:2393-2402. DOI: https://doi.org/10.1016/S0140-6736(17)30555-X

Babl FE et al. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr. 2014. 13;14:148. DOI: 10.1186/1471-2431-14-148

Singh S et al. The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma. Acad Emerg Med. 2020. 27:832–843. DOI: 10.1111/acem.13942

Borland M et al. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study. Ann Emerg Med. 2019. 74:1-10. DOI: 10.1016/j.annemergmed.2018.11.035

Concussion: Neha Raukar at DFTB19

Cite this article as:
Team DFTB. Concussion: Neha Raukar at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22181

After spending 12 years as the Director of the Division of Sports Medicine in the Department of Emergency Medicine at the Warren Alpert Medical School at Brown University, Dr. Raukar joined the Department of Emergency Medicine at the Mayo Clinic in 2018 as full-time faculty.

In this fascinating talk she explores what happens to those children we see every weekend in the emergency department. Whether it is a clash of elbow versus head on the footy oval or a punch to the face at karate practice or something as innocuous as a simple fall from the monkey bars we don’t give these head injuries the attention they deserve.

 

 

©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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Bubble Wrap Live – Top 5 papers in PEM: Edward Snelson at DFTB19

Cite this article as:
Team DFTB. Bubble Wrap Live – Top 5 papers in PEM: Edward Snelson at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22057

In the three years since we launched the Bubble Wrap segment, we have been able to highlight a number of key articles in paediatric research.  In this talk from the popular Bubble Wrap Live! sessions, Edward Snelson brought us his top five favourite articles from the world of paediatric emergency medicine.

He eloquently confronts his own biases and suggests a more critical way of looking at the patient in front of us.

 

Here are the five articles Edward chose.

Foster SJ, Cooper MN, Oosterhof S, Borland ML. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine. 2018 Feb 1;6(2):97-106.
 
Kuppermann N, Dayan PS, Levine DA, Vitale M, Tzimenatos L, Tunik MG, Saunders M, Ruddy RM, Roosevelt G, Rogers AJ, Powell EC. A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections. JAMA pediatrics. 2019 Apr 1;173(4):342-51.
 
Borland ML, Dalziel SR, Phillips N, Lyttle MD, Bressan S, Oakley E, Hearps SJ, Kochar A, Furyk J, Cheek JA, Neutze J. Delayed presentations to emergency departments of children with head injury: a PREDICT study. Annals of emergency medicine. 2019 Jan 14.
 
Abe T, Aoki M, Deshpande G, Sugiyama T, Iwagami M, Uchida M, Nagata I, Saitoh D, Tamiya N. Is Whole-Body CT Associated With Reduced In-Hospital Mortality in Children With Trauma? A Nationwide Study. Pediatric Critical Care Medicine. 2019 Jun 1;20(6):e245-50.
 
Lyttle MD, Rainford NE, Gamble C, Messahel S, Humphreys A, Hickey H, Woolfall K, Roper L, Noblet J, Lee ED, Potter S. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE): a multicentre, open-label, randomised trial. The Lancet. 2019 May 25;393(10186):2125-34.
 
 
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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Bubble Wrap Live 2019 – Article List

Cite this article as:
Team DFTB. Bubble Wrap Live 2019 – Article List, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.20064

At DFTB19, we had three great talks during the Bubble Wrap Live session. Whilst the videos and podcasts from these talks are still in the works, here’s the list of articles referenced for you to check out ahead of time.

5 Paediatric Emergency Papers

Edward Snelson @sailordoctor

PREDICT: Head Injury and Delayed Presentations to ED

Borland ML, et al. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study. Annals of Emergency Medicine, 2018;75 (1):1-10

Oral Prednisolone for preschool viral induced wheeze

Foster SJ, et al. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine. 2018;6(2):97-106

Clinical Prediction Rule for Febrile Infants under 60 days

Kupperman N, et al. A Clinical Prediction Rule to Identify Febrile Infants 60 Days and Younger at Low Risk for Serious Bacterial Infections. JAMA Pediatr.2019;173(4):342-351. doi:10.1001/jamapediatrics.2018.5501

Whole body CT for children with Trauma

Abe T, et al. Is Whole-Body CT Associated With Reduced In-Hospital Mortality in Children With Trauma? A Nationwide Study. Pediatr Crit Care Med. 2019 Jun;20(6):e245-e250. doi: 10.1097/PCC.0000000000001898.

ECLIPSE study

Lyttle MD, et al. Levetiracetam versus phenytoin for second-line treatment of paediatric convulsive status epilepticus (EcLiPSE). The Lancet . 2019;393(10186):2125-2134

 

5 General Paediatrics Papers

Susie Piper @chookiemama

Probiotics and Gastroenteritis

Freedman SB, et al. Multicenter Trial of a Combination Probiotic for Children with Gastroenteritis. N Engl J Med 2018; 379:2015-2026 DOI: 10.1056/NEJMoa1802597

Acetaminophen and Febrile Seizure Recurrence

Murata S, et al. Acetaminophen and Febrile Seizure Recurrences During the Same Fever Episode. Pediatrics 2018; 142(5): pii: e20181009. doi: 10.1542/peds.2018-1009. Epub 2018 Oct 8.

Hi flow vs CPAP in SCN (HUNTER trial)

Manley BJ, et al. Nasal High‐Flow for Early Respiratory Support of Newborn Infants in Australian Non‐Tertiary Special Care Nurseries (The Hunter Trial): A Multicentre, Randomised, Non‐Inferiority Trial. J Paediatr Child Health. 2018;54:4-4. doi:10.1111/jpc.13882_4

Rudeness and Medical Performance

Riskin A, et al. The Impact of Rudeness on Medical Team Performance: A Randomized Trial. Pediatrics. 2015;136:487-495.

Katz D, et al. Exposure to incivility hinders clinical performance in a simulated operative crisis.

LEGO and poo!

Tagg A, et al. Everything is awesome: Don’t forget the Lego.  2018 Nov 22. doi: 10.1111/jpc.14309. [Epub ahead of print]

 

Paediatric Surgery Papers

Craig McBride @paedsurg

Tissue Paper: Paediatric Burn Wound Care

Brown E.A, et al. Impact of Parental Acute Psychological Distress on Young Child Pain-Related Behavior Through Differences in Parenting Behavior During Pediatric Burn Wound Care. J Clin Psychol Med Settings (2019). https://doi.org/10.1007/s10880-018-9596-1

Brown NJ, et al. Play and heal: Randomized controlled trial of Ditto™ intervention efficacy on improving re-epithelialization in pediatric burns. Burns. 2014;40:204–13.

Paper Planes: Telehealth in Paediatrc Surgery

Brownlee GL, et al. Telehealth in paediatric surgery: Accuracy of clinical decisions made by videoconference. J Paediatr Child Health. 2017;53(12)

Rees CM, et al. Probiotics for the prevention of surgical necrotising enterocolitis: systematic review and meta-analysis.

Sandpaper: Bullying & Discrimination in Surgery

Crebbin, W. , Campbell, G. , Hillis, D. A. and Watters, D. A. (2015), BDSH in surgery in Australasia. ANZ J Surg, 85: 905-909. doi:10.1111/ans.13363

Watters, D. A. (2015), Apology for discrimination, bullying and sexual harassment by the President of the Royal Australasian College of Surgeons. ANZ J Surg, 85: 895-895. doi:10.1111/ans.13362

 

 

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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Top 5 Papers in PEM

Cite this article as:
Tessa Davis. Top 5 Papers in PEM, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18476

This post is based on a talk I presented at the RCEM Spring Conference in April 2019 – Top 5 papers in PEM.

Kylie and Jason are enjoying their time at home with their first baby. The highs of being new parents is at its peak and true sleep deprivation is yet to set in. Jayden is two weeks old and is simply perfect. They spend hours staring at him each day marvelling at the perfect human they have created. 

As we follow Jayden through his journey to adulthood, we’ll encounter some common paediatric problems. The 5.5 papers I have chosen were selected because: they cover common presentations; they use large patients groups; and they were conducted by well-respected and highly regarded research groups. But back to our story…

 One night Jayden seems a bit more unsettled than normal. When they check his temperature it’s 38.4. They get in the car and bring Jayden to ED

 Febrile neonates are a huge source of concern – we know that they can deteriorate quickly and we usually err on the side of caution by doing a full septic screen, IV antibiotics, and admission. Actually many of these babies don’t have a serious bacterial infection. Is there a way to tell which ones do?

When you see Jayden in your ED, you ask yourself is…should I do a full septic screen?

Paper 1 - Kupperman et al, 2019, A clinical prediction rule to identify febrile infants 60 days and younger at low risk for serious bacterial infections, JAMA Pediatrics


This paper aimed to derive and validate a highly accurate prediction rule to identify infant at low risk of SBI. The patients were febrile infants 60 days and younger (who had a rectal temp of >38 in the ED or a fever at home within the preceding 24 hours)

They excluded those who were critically ill, who had antibiotics in the preceding 48 hours, those born premature, and those with other medical conditions.

There were 1821 febrile infants included.

The authors considered clinical suspicion of SBI. They then look at various markers: blood culture; urine culture and urinalysis; CSF; FBC; and procalcitonin levels. The outcomes  considered were serious bacterial infection – that is bacterial meningitis, bacteraemia, or urinary tract infection.

Overall, the rates of SBI in this group was 9%. The authors formulated a rule with a very high sensitivity (97.7%) for identifying those at low risk of serious bacterial infection. They were low risk if they fulfilled three criteria:

  • negative urinalysis
  • neutrophil count of less than 4/mm3 
  • procalcitonin of less than 0.5ng/ml

61.3% of their patient group were low risk.

Interestingly their low risk rule does not include use of  lumbar puncture67.4% of the low risk group had a lumbar puncture that would not have been necessary.

Key take away: There may be some febrile neonates that are low risk, and therefore we could avoid a lumbar puncture and full work up. In practical terms, this is unlikely to change our practice at the moment. Many of us cannot send a procalcitonin in the ED, and we might have to wait several hours to get a neutrophil count back. However this does bode well for the future in identifying which of these well febrile neonates are low risk.

Jayden does get a full septic screen. He has IV antibiotics for 48 hours and remains well. His blood cultures are negative so his antibiotics are stopped and he is discharged.

FLASH FORWARD…

 

 

Jayden is growing well. At 7 months of age, he is looking great and developmentally normal. Dad, Jason, smokes, but reassures you that he never does so in the house. Jayden develops a cough and two days later starts breathing very quickly and noisily. They head to the emergency department.

Jayden has bronchiolitis. This is very common and your departments and wards have no doubt been filled with these children over the winter. We know that little works with these children. So you force yourself to hold back the ‘trial of salbutamol’ because it won’t make any difference.. But high flow does seem to be the one thing (along with oxygen) that might make a difference.

You ask yourself the question...should I start high flow?

Paper 2 - Franklin et al, A Randomized Trial of High-Flow Oxygen Therapy in Infants with Bronchiolitis. NEJM. 2018. 378(12):1121-1131

This study looks at infants under 12 months old with a clinical diagnosis of bronchiolitis and a need for supplemental oxygen. 1472 were included (after exclusions). Patients were excluded if: they had an alternative diagnosis; they had cyanotic heart disease; or they were on home oxygen.

Patients were randomised to either high flow or low flow. The high flow group were given heated humidified high flow oxygen – 2L/kg/min via Optiflow. The oxygen was then weaned to achieve target saturations, and they were taken off high flow once they had been on air for four hours. The low flow group were given wall oxygen via nasal cannulae at 2L/min max.

The outcome  was escalation of care. This meant who in the low flow group was escalated to high flow, and who in the high flow group was escalated to BiPAP or was intubated. Treatment failure was based on: an increase in heart rate; if the respiratory rate increased or didn’t drop; if they were needing oxygen in >2L/min of flow or >0.4 FiO2 to maintain their saturations; or if they achieve a high early warning score. Clinicians could also escalate care themselves (34% were escalated in this way).

Escalation of care occurred much more commonly in the low flow group – with 12% being escalated in the high flow group and 23% in the low flow group.

 

Interestingly there was no difference in the length of stay between the two groups.

Key take away: High flow does reduce the need for escalation. Escalation itself is significant – it requires increased nursing attention for low flow patients while they are transferred onto Optiflow.  There may be less medical staffing on the wards if the child deteriorates on high flow overnight. Although they aren’t comparing like with like, escalation itself is an important clinical event. They also demonstrated that high flow does not increase the number of adverse events (for example there was no difference in the number of pneumothoraces between the groups). High flow is safe to use and we should consider starting it early in ED.

You start Jayden on high flow in ED and he stabilises. 12 hours later he is weaned off on the ward and is discharged the following day.

FLASH FORWARD…

Jayden is now a healthy 3 year old boy. He loves Paw Patrol.  He hates vegetables and won’t eat any food that is the colour green or yellow. Kylie and Jason are expecting their next child, and Jason has finally quit smoking. Unfortunately Jayden is prone to wheezy episodes and now has his very own inhaler which he hates using. The change in weather in London, from quite cold to…colder, seems to have triggered something and he’s now pretty wheezy and short of breath. They head into their favourite emergency department.

 Jayden is now firmly in the realm of viral-induced wheeze. Yes, it’s all on a spectrum, but he’s now 3 years old with an inhaler. You asses him and think he should have a salbutamol burst.

As you are writing the salbutamol up, your SHO asks  you – should I give him steroids?

Paper 3 - Foster SJ, Cooper MN, Oosterhof S, Borland ML. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancet Respiratory Medicine. 2018 Jan 17.

 This paper aimed to assess the efficacy of oral prednisolone in children presenting to an ED with viral wheeze.

The patients included were 2-6 years old. They were excluded if: saturations were less than 92% in air; they had a silent chest; they had sepsis; there was a previous PICU admission for wheeze; they had prematurity; or they had recently had steroids.

605 patients were included and they were randomised to receive either prednisolone or placebo. The prednisolone group received 1mg/kg prednisolone once a day for three days. The placebo group received a placebo medication (matched for volume and taste to prednisolone) once a day for three days.

Patients were assessed for their wheeze severity using a validated pulmonary score.

The outcome measures were length of stay (until clinically fit for discharge). They also considered re-attendance, readmission, salbutamol usage, and residual symptoms.

The results are tricky to interpret. Those who were discharged from ED within four hours did not benefit from prednisolone. However there may be some benefit in the mild to moderate wheeze group, and some in those who used salbutamol at home prior to presenting to ED. Interestingly this paper did not support our previously held belief that those children with atopy respond better to prednisolone.

 Key take homes: Some pre-schoolers are steroid responsive, but identifying which ones is a challenge. As Damian Roland discusses here, it is likely that we are seeing lots of children presenting with the same symptoms (wheeze) but with different pathology behind it. Once we can identify the pathology we can start to target specific groups of patients with management that works.

You decided not to give Jayden prednisolone and after his salbutamol burst he stretches to 4 hours and is discharged home.

FLASH FORWARD…

Jayden is 5 years old and in his excitement of building the new Hogwarts Lego castle he accidentally swallows a Lego head. Kylie and Jason aren’t sure whether to worry or not? So they take him into ED.

Children ingesting random objects is a common presentation to ED.

When you see Jayden in the department, his parents ask you…should I search through his poo?

Paper 3.5 - Tagg, A. , Roland, D. , Leo, G. S.Y., Knight, K. , Goldstein, H. , Davis, T. , DFTB, (2018), Everything is awesome: Don’t forget the Lego. J Paediatr Child Health. doi:10.1111/jpc.14309

Myself and 5 of my fearless, and brave, paediatric colleagues swallowed a Lego head each to see how quickly it passed. The paper was generously published in the Journal of Paediatrics and Child Health.

To ensure serious scientific rigour, we put together some scoring systems.

The Stool Hardness and Transit time (the SHAT score) took into account how hard our stools were, and whether that impacted (no pun intended) on the time to retrieve the Lego head.

And out main outcome was the Found And Retrieved Time (the FART score). This was the time to get our Lego heads back, and the average FART score was 1.71 days.

Unfortunately one of the six of us didn’t find his Lego head. After valiantly searching through his own faeces for two weeks, he gave up. And it may still be up there.

Key take home: Don’t search through poo, it’s gross.

Jayden heads home happily to finish building his Lego Castle.

FLASH FORWARD.

Jayden is 6 years old. He thinks Paw Patrol is for losers. Fortunately he still loves Lego and Harry Potter. He also enjoys climbing. Unfortunately, two days ago he fell off the ladder coming down from his bunk bed. He seemed okay at the time, and Kylie and Jason had other plans that evening, so they decided to keep him at home. Now, two days later, he has a massive egg on his head and has been complaining of a headache. He also vomited yesterday. They bring him to ED.

 

We have fabulous head injury guidance for kids thanks to PECARN, CHALICE, and CATCH. But actually PECARN and CATCH specifically exclude injuries more than 24 hours old, and CHALICE doesn’t publish data on this group. So, for Jayden you need to put the NICE guideline away because it doesn’t apply. This is a common grey area.

The question you ask is….should I scan his head?

Paper 4 - Borland M, Dalziel SR, Phillips N, Lyttle M, Bressan S, Oakley E, Hearps SJC, Kochar A, Furyk J, Cheek J, Neutze J, Gilhotra Y, Dalton S, Babl F. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study, Annals of Emergency Medicine, DOI: https://doi.org/10.1016/j.annemergmed.2018.11.035

This paper aimed to establish the prevalence of traumatic brain injuries in children presenting more than 24 hours after the head injury.

Traumatic brain injury (TBI) was defined as: intracranial haemorrhage; contusion; cerebral oedema; diffuse axonal injury; traumatic infarction; shearing injury; or a sigmoid sinus thrombosis.

The also looked a clinically significant traumatic brain injury (cTBI) – this included death, intubation for more than 24 hours, neurosurgery, or admission for 2 or more nights to hospital.

The patients were from the Australian Paediatric Head Injury Study Cohort which was 20,137 patients. 5% of these presented over 24 hours after the injury. 981 children were included in this study.

The authors considered the injury characteristics and demographics, trying to find an association between mechanism and delay in presentation. Those presenting were more likely to have: a non-frontal scalp haematoma; headache; vomiting; and assault with NAI concern. Those with loss of consciousness and amnesia were more likely to have presented within the first 24 hours.

The CT rates were much higher in the late presentation group – 20.6% being scanned in the delayed group and only 7.9% in the early group. This probably reflects the lack of evidence in this area, and therefore we feel safer doing more scans.

But the rates of TBI also varied. 3.8% in the delayed presentation group had a TBI, whereas only 1.2% in the early presentation group did.

The rates cTBI were the same between the groups at 0.8%

Key take homes: There is an increased risk of TBI when presenting more than 24 hours after a head injury injury. The authors found that risk is increased if the patient has a non-frontal scalp haematoma or a suspicion of a depressed skull fracture.

You decide to scan Jayden’s head, but it turns out to be normal and he is discharged home.

FLASH FORWARD… 

Jayden is 8. He’s been drinking a LOT of water over the last few weeks and seems to be weeing constantly. His clothes seem a bit big for him too. He looks so bad one day (and has vomiting and abdominal pain) that Jason finally reneges and takes him into ED.

Jayden has DKA. The debate about over-zealous fluid administrations and its relationship to the dreaded cerebral oedema is long-standing. Previous research suggested a link but only by association, not causality.

You ask yourself…how fast should I give IV fluids?

Paper 5 - Kupperman et al. Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis NEJM 2018 vol 378 (24) pp 2275-2287

The study examines the causal effect between fluid resuscitation and cerebral oedema.

They included 1389 episodes of DKA. Exclusions were mainly due to too much management prior to contact with the study team, as well as children with a GCS<12. The median age was 11. It should be noted that the very young and the very sick are probably lost in this cohort.

Patients were randomised to received either fast or slow rehydration, and then were split again into received either 0.9% NaCl or 0.45% NaCl.

The fast rehydration group received 20ml/kg bolus and then replacement of 10% deficit, half over 12 hours and rest over next 24 hours. The slow rehydration group received a 10ml/kg bolus and then replacement of 5% deficit over 48 hours. Maintenance fluids and insulin were given in addition.

The outcomes looked at were deterioration of neurological status within first 24 hours of treatment. They also assessed short term memory during treatment, and IQ 2-6 months after the episode of DKA.

In short, they found no difference between the groups. There was a 0.9% rate of brain injury overall and it didn’t matter which type of fluids or how fast. Patients were more likely to get hyperchloraemic acidosis in the 0.9% NaCl group but this is of debatable clinical significance.

Key take homes: The evidence does not support our traditionally cautious approach to DKA. The speed of IV fluids does not seem to be the cause of brain injury in DKA.

You resuscitate Jayden and send him off to the ward. He is discharged a few days later with good support from the Endocrine team for management of his diabetes.

FLASH FORWARD…

Jayden is now 16 years old and next time he comes to ED, he’ll be in the harsh world of Adult ED. We have navigated him through his common childhood presentations to ED and answered the key questions we ask ourselves every day in the Paeds ED.

 

Should I do a full septic screen on this hot baby?

Should I start high flow on this infant with bronchiolitis?

Should I give prednisolone to this 2 year old with wheeze?

Should I scan this child with a head injury?

How fast should I give fluids to my DKA?

And most importantly, do I ever need to sift through my child’s poo, or my own ever again?