Toddler fracture

Cite this article as:
Rhiannon McClaren. Toddler fracture, Don't Forget the Bubbles, 2021. Available at:
https://doi.org/10.31440/DFTB.31170

A 2-year-old girl, Aila, presents to the emergency department with her mother. She had been running around at childcare playing with her friends when she fell over. She is upset, has refused to walk since and won’t weight bear on her right leg. On examination, there is no obvious swelling or deformity and on palpation and axial loading it appears that her pain is most likely localised to her right lower leg, but it’s hard to be sure.

A toddler’s fracture is a non-displaced spiral fracture of the distal two-thirds of the tibial shaft, with an intact fibula, occurring in children generally between the ages of 9 months and 3 years. The periosteum remains intact. It was first described in 1964 by Dunbar et al. It is thought to be due to new stresses on the bone due to increasing ambulation.

History and examination

The mechanism is usually trivial, a trip or a fall, and often involves a twisting mechanism. Sometimes a specific story of trauma is difficult to elicit. More commonly children present unwilling to bear weight or limping with non-specific examination findings. They may be tender to palpation of the tibia, have pain with dorsiflexion of the ankle or pain with gentle twisting of the lower leg. All joints of the lower limb should be examined. It is always worth examining both lower limbs as gait can be difficult to assess in toddlers and may be misleading regarding the side of the injury.

As part of a thorough history and examination, any history of fever, weight loss, recent illness, or recurrent presentations with minor injuries should be elicited. The child should have their spine and neurology examined as well as any bruising, petechiae, warmth and swelling of joints, and puncture wounds on the soles of the feet documented.

Imaging

Initial x-rays may show a non-displaced spiral fracture of the tibia, however, a fracture may not be seen despite multiple views. AP and lateral views should be adequate in children, however, an oblique view may help. A repeat x-ray in 1 week usually shows sclerosis or periosteal reaction. 

AP and Lateral of lower limb
Case courtesy of Dr Jeremy Jones, Radiopaedia.org. From the case rID: 9317
Periosteal reaction and callus formation in healing toddlers fracture
Case courtesy of Dr Sebastian Tschauner, Radiopaedia.org. From the case rID: 49123

But, a plain film x-ray may not be where it ends. Ultrasound is being explored as a possible diagnostic tool for toddler’s fracture, as sonography is used more and more for diagnosis of long bone fractures in children. The idea’s not a new one; a case report of three children in England in 2006 demonstrated that Point of Care Ultrasound Scan (POCUS) could be used to diagnose toddler’s fracture where initial x-rays did not show any fractures. They used the appearance of an elevated periosteum and a layer of low reflectivity superficial to the tibial cortex which suggests a fracture haematoma as a way of diagnosing an occult fracture. 

Cortical breach seen on ultrasound
Ultrasound image showing cortical breach in a toddler’s fracture. Image courtesy of Dr Casey Parker as found in Clinical Case 111: Toddler’s Tibia Tale published January 18, 2015, available at https://broomedocs.com/2015/01/clinical-case-111-toddlers-tibia-tale/

A recent pilot study by Carsen et al comparing ultrasound to radiographic diagnosis of toddler’s fractures looked at 27 children presenting with suspected toddler’s fractures. Five children had confirmed toddler’s fractures and of these five, three were identified correctly by x-ray at initial presentation and the other two were diagnosed with repeat x-ray at follow up appointments. All five children had their toddler’s fracture correctly identified using POCUS at their initial presentation. 

Radiograph showing Toddler fracture
AP x-ray of the same toddler’s fracture seen on ultrasound. Image courtesy of Dr Casey Parker as found in Clinical Case 111: Toddler’s Tibia Tale published January 18, 2015, available at https://broomedocs.com/2015/01/clinical-case-111-toddlers-tibia-tale/

Although there are limited studies evaluating the use of POCUS in the diagnosis of toddler’s fractures, the small number of studies and case studies available are promising. As a point of care test in someone with appropriate training, this is a convenient potential diagnostic tool, particularly given the potential to reduce radiation exposure for children.

Management

Toddler’s fractures do not need to be reduced and the management is largely supportive for 3-4 weeks. Standard treatment is a long leg back slab followed by a long leg walking cast. 

A number of retrospective studies have looked at rates of immobilising toddler’s fractures when the diagnosis is either confirmed or presumed. They show that children with confirmed toddler’s fractures are more likely to be immobilised. But… a series of 75 children with radiographic evidence of toddler’s fractures, by Schuh et al., looked outcome following a variety of treatments (cast/splint, controlled ankle movement boot, or no immobilisation). Those not immobilised had fewer follow up appointments and fewer repeat radiographs. Skin breakdown was reported in 17% of children, all of whom were in a splint or cast. Schuh et al. also found that children who were not immobilised walked much earlier than those who were immobilised in a controlled ankle movement (CAM) boot or splint. It was a mean of 4.1 days for the little ones not immobilised compared to 27.0 days for the smallies in a boot and a whopping 27.5 days for those in a cast or splint.  

Another retrospective study by Bauer and Lovejoy of 192 children, aged 9 months to 4 years, meeting criteria for a toddler’s fracture, showed an earlier return to weight-bearing in those immobilised with a CAM boot compared with a short leg cast (2.5 vs 2.8 weeks). Even when considering the seven children in this study who received no immobilisation, none of the fractures shifted. Sapru and Cooper also found that there were no complications with management in or out of a cast.  

There is now a move towards recommending immobilisation in a CAM boot or short leg cast or splint rather than in a long leg cast. Further studies are currently underway so watch this space!

What not to miss

A thorough history and examination should always be taken so as not to miss other diagnosis. If a child is not yet mobile, there must be a high suspicion for non-accidental injury. Fevers warrant consideration of septic arthritis or osteomyelitis. Malignancy and inflammatory conditions should also be considered. 

Aila’s initial x-ray showed a non-displaced spiral fracture of the distal third of her right tibia. She was placed in a long leg back slab and had a follow-up with the local orthopaedic service in the fracture clinic. Four weeks later she is running around and happily playing with her older brother.

 References

Alqarni, N., & Goldman, R. D. (2018). Management of toddler’s fractures. Canadian family physician Medecin de famille canadien64(10), 740–741. 

Bauer, J.M., Lovejoy, S.A. (2019) Toddler’s Fractures: Time to Weight-bear with Regard to Immobilization Type and Radiographic Monitoring. J Pediatr Orthop. Jul: 39(6), 314-317. 

Carsen, S., Doyle, M., Smit, K., Shefrin, A., Varshney, T. (2020) Point-of-care Ultrasound in the Emergency Department may provide more accurate diagnosis of toddler fractures than radiographs: A pilot study. Orthopaedic Proceedings. 102-B

Dunbar, J.S., Owen, H.F., Nogrady, M.B., McLeese, R., (1964) Obscure Tibial Fracture of Infants – The Toddler’s Fracture. Journal of the Canadian Association of Radiologists, Sep;15, 136-144. 

Fox, S. (2013) Toddler’s Fracture. Available at: https://pedemmorsels.com/toddlers-fracture/

Lewis, D. and Logan, P. (2006), Sonographic diagnosis of toddler’s fracture in the emergency department. J. Clin. Ultrasound. 34: 190-194. 

Pattishall, A.E. (2019) An updated approach to toddler fractures. J Urgent Care Med.  Available at: https://www.jucm.com/an-updated-approach-to-toddler-fractures/

Rasuli, B., Gaillard, F. Toddler Fracture. Available at: https://radiopaedia.org/articles/toddler-fracture

Royal Children’s Hospital Guidelines – Tibial Shaft Fractures. Available at: https://www.rch.org.au/clinicalguide/guideline_index/fractures/tibial_shaft_emergency/

Sapru, K., Cooper, J.G. (2014). Management of the Toddler’s fracture with and without initial radiological evidence. Eur J Emerg Med. Dec;21(6), 451-454. 

Schuh, A.M., Whitlock, K.B., Klein, E.J. (2016) Management of Toddler’s Fractures in the Pediatric Emergency Department. Pediatri Emerg Care.  Jul: 32(7), 452-454.

UpToDate – Tibial and fibular shaft fractures in children

Wang, C.C., Linden, K.L., Otero, H.J. (2017) Sonographic Evaluation of Fractures in Children. Journal of Diagnostic Medical Sonography. 33(3), 200-207. 

Wijtzes, N., Jacob, H., Knight, K., Thrust, S., Hann, G. (2020) Fifteen-minute consultation: The toddler’s fracture. Arch Dis Child Educ Pract Ed. 0, 1-6. 

POCUS: Russ Horowitz and Cian McDemott at DFTB19

Cite this article as:
Team DFTB. POCUS: Russ Horowitz and Cian McDemott at DFTB19, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.22174

Where would the world of paediatrics be without POCUS? We’d still be trying (and failing) to cannulate chubby toddlers by feel alone, we’d still be using radioactive waves to determine if the child in front of us has pneumonia and we wouldn’t have this eye-opening talk from Russ and Cian.

©Ian Summers

 
Russ and Cian co-ordinated the wonderful pre-conference ultrasound workshop in London.  Here is one of our favourite pearls is you want to help identify the bladder before performing a SPA. The bladder, looking just like a slice of toast, makes the perfect target.
 
 
 
If this talk has whetted your appetite then why not sign up for one of the www.dftb20.com ultrasound workshops.

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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Selected References

Sii F, Barry RJ, Abbott J, Blanch RJ, MacEwen CJ, Shah P. The UK Paediatric Ocular Trauma Study 2 (POTS2): demographics and mechanisms of injuries. Clinical ophthalmology (Auckland, NZ). 2018;12:105.

Imaging in COVID

Cite this article as:
Nuala Quinn, Cian McDermott and Gabrielle Colleran. Imaging in COVID, Don't Forget the Bubbles, 2020. Available at:
https://doi.org/10.31440/DFTB.24680

The current pandemic is providing a challenge in healthcare settings whose resources are rapidly becoming strained. From the early experiences in China, it appears that children who are infected with COVID-19 have a milder course typically than that seen in adults. The radiological findings in adults include multifocal bilateral ground-glass opacities and consolidation. This is often peripheral or basal in distribution. They tend to evolve from either these bilateral ground-glass opacities on the periphery to consolidation then crazy paving. The limited initial data in children suggest that multi-lobar involvement is much less common. This is consistent with the hypothesis that children appear to have milder disease. Findings peak at 7 to 14 days and then gradually resolve. We do not yet know the radiologic sequelae.  Experience taken from the adult population in Ireland has also noted air leak complications including pneumomediastinum and pneumothorax. Pleural effusions, lymphadenopathy, and tiny lung nodules seem to be less common manifestations.

 

X-ray

The chest x-ray is, in general, the first-line imaging in children with respiratory pathology. And it is being used in COVID-19. This (pre-publication) CXR is from a case in a tertiary paediatric hospital. It shows bilateral mid-zone and left lower zone patchy consolidation and pneumomediastinum.

Ming-Yen et al describe five patients who had both chest x-rays and a CT of the thorax. Two patients showed normal CXR findings, despite having a CT examination on the same day showing ground-glass opacities. The positive CXR findings seem to appear later in the disease progression. Within the Guangdong province of the authors, a CT of the thorax is now being requested on every patient suspected of having COVID-19 regardless of risk. However, the radiation associated with CT in children does not, and cannot, support this in the paediatric setting. In sticking to the ALARA (As Low As Reasonably Achieivable) we should consider the use of another evidence-based resource – point-of-care ultrasound (POCUS).

Point of care ultrasound (POCUS) is fast becoming an established part of paediatric emergency medicine. Lung ultrasound is a mainstay of POCUS for a variety of diagnoses including pneumonia and pleural effusion. Now, there is rapidly evolving evidence on COVID-19 and POCUS lung findings.

So, how do we use ultrasound to look for ground-glass opacification and consolidation in children with suspected viral respiratory tract infection?

 

Sonographic characteristics

 

Lung US is more sensitive than CXR for interstitial patterns, small effusions, and subpleural thickening. The POCUS characteristics are similar to other causes of viral pneumonia, but in COVID-19, two studies (Huang et al and Peng et al) also described localized pleural effusions. They are more often seen with bacterial pneumonia in children, rather than viral. Large volume pleural effusions are uncommon – if you are seeing this then you need to consider other pathology.

B-lines are short-path reverberation artefacts that are found in many pathological and nonpathological states. *ISP is interstitial syndrome pattern, i.e. extensive B lines which may coalesce. This pattern is not unique to COVID-19. It is also commonly seen in pulmonary oedema. In COVID-19 these may appear in characteristic focal, multifocal and confluent patterns.

Small subpleural consolidations may be also seen. These are small hypoechoic areas inferior to the pleural line. If there is bibasal consolidation on the ultrasound, there may also be dynamic bright air bronchograms present. In COVID-19, a pleuropathy develops. This results in a thickened, irregular appearance of the pleura. There may also be skip lesions – normal pleura alongside thickened pleura with associated B-lines.

It is important to note that children may be clinically well with any of the positive lung POCUS findings.

Technique tips

The technique for POCUS lung is well described. However, for children and COVID, the following may be helpful:

  • Use the linear probe to assess pleura and look for pleural line thickening, small superficial effusions, skip lesions and B-lines.
  • Use the curvilinear or phased for lung windows. It may also be better for posterior pathology such as consolidation and air bronchograms.
  • Turn off the harmonics and spatial functioning.

And if you don’t know what any of that means then head over to Practical Pocus for a free online course and follow @Zedunow for their daily updates.

 

Decontamination and machine preparation

Infection control measures are key – the machine should go in clean and come out clean! ACEP have published an excellent COVID US cleaning protocol which is really worth a look at.

Remember to strip the machine of all non-essential items such as trays, holders and inserts and where possible avoid keyboards and use the touchscreen. Rather than multi-use bottles of gel, you should be using single-use sachets.

Handheld devices provide an alternative, with less cleaning required.

 

Photo courtesy of Cian McDermott

A word on CT

The CT findings associated with COVID-19 have been widely described: ground-glass opacities and consolidation with or without vascular enlargement, interlobular septal thickening ,and air bronchograms. Most of the studies are in affected adults and the high reported sensitivity will be affected by patient selection bias. Like the chest x-ray, it may be falsely negative in the first few days of illness. A normal CT early in disease could be falsely reassuring. Indeed, the general guidance from numerous faculties of radiology does not currently recommend CXR or CT to diagnosed COVID-19. Viral testing remains the gold standard.

 

Finally, a word on ALARA

ALARA, or making every effort to limit exposure to radiation As Low As Reasonably Achievable, is particularly relevent in COVID-19. Imaging should only be conducted for those patients where imaging will impact management of the condition. These recommendations may change as our knowledge of COVID evolves. CXR, CT and POCUS each have their own limitations, but there is emerging evidence that POCUS, in the hands of a competent practitioner, is superior in ease of access, diagnostic ability and ease of decontamination, particularly at a time when infection control is so crucial.

 

Selected references

Kanne JP, Little BP, Chung JH, Elicker BM, Ketai LH. Essentials for Radiologists on COVID-19: An Update-Radiology Scientific Expert Panel. Radiology. 2020 Feb 27:200527. https://pubs.rsna.org/doi/pdf/10.1148/radiol.2020200527.

Liu M, Song Z, Xiao K.High-Resolution Computed Tomography Manifestations of 5 Pediatric Patients With 2019 Novel Coronavirus.J Comput Assist Tomogr. 2020 Mar 25.

Ming-Yen N et al. Imaging Profile of the COVID-19 Infection: Radiologic Findings and Literature Review. Radiology 2020 Feb 13 https://doi.org/10.1148/ryct.2020200034

Huang Y et al. A Preliminary Study on the Ultrasonic Manifestations of Peripulmonary Lesions of Non-Critical Novel Coronavirus Pneumonia (COVID-19) SSRN 2020 Feb 28 https://dx.doi.org/10.2139/ssrn.3544750

Peng, Q., Wang, X. & Zhang, L. Findings of lung ultrasonography of novel corona virus pneumonia during the 2019–2020 epidemic. Intensive Care Med (2020). https://doi.org/10.1007/s00134-020-05996-6

Li Y, Xia L. Coronavirus Disease 2019 (COVID-19): Role of Chest CT in Diagnosis and Management. AJR Am J Roentgenol. 2020 Mar 4:1-7. doi:10.2214/AJR.20.22954

 

International Society Guidelines

Royal Australian and New Zealand College of Radiologists

Canadian Association of Radiologists 

American College of Radiology statement on CXR and CT findings in COVID19

Royal College of Radiology statement on CT in COVID

We’ve only just begun…

Cite this article as:
Andrew Tagg. We’ve only just begun…, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.19490

As we prepare for the opening of #DFTB19 and meeting friends from all over the world it’s great to see everyone getting stuck into the workshops.

The Compassion Lab

Mary Freer is the Fairy Godmother of the DFTB conferences. Since she spoke at DFTB17 we have been awed at her passion for compassion. This year she ran a boutique Compassion Lab to help bring a little more kindness to our workplace.

In our time poor, resource poor workplaces it can be a challenge to be kind, both to ourselves, each other, and our patients.

If you couldn’t make it over to London then there are still some tickets left for her Compassion Revolution in Melbourne.

Presentation skills 2.0

We like to challenge our speakers to step out from behind the lectern and bring their ‘A’ game. This can be quite confronting when you are used to watching the usual ‘death-by-powerpoint’ type of talk. To make it easier for our speakers Grace Leo and Ross Fisher have, once again, acted as speaker coaches. But we didn’t want only just our speakers to benefit from their wisdom.

Over the course of the day they took delegates from the basics of the P3 methodology to the next level of presenting. We are really looking forward to hearing their pitches for next year.

The Power of POCUS

Ultrasound is the way forward in paediatric imaging and for our two workshops Cian McDermott and Russ Horowitz had an amazing team to help them. With the support of GE Healthcare and Jon Robinson delegates were rotated around a variety of stations to test their ultrasound chops.

They were joined by Resa Lewiss, Mike Griksaitis, Avi Sarfatti and Toni Hargadon-Lowe.

We were lucky to have some very patient paediatric models to tell our ultrascoundrels if they were pushing too hard or putting the probe in the wrong place. We even managed to come up with a new US sign – let’s hope the Toast sign of a full bladder catches on.

Let’s Play Make Believe

A crack team of simulationistas led by Ian Summers ran two sessions on Sunday. Starting with a simulation design workshop and ably abetted by Sandra Viggers, Camille Sorensen, Morten Lindkvist, Damian Roland and LifeCast the group were set the task of designing in situ simulation scenarios with the child in mind.

The afternoon session was led by Walter Eppich who took the delegates through the power of debriefing. He is a man who has spent a lot of time thinking about debriefing.

Bajaj K, Meguerdichian M, Thoma B, Huang S, Eppich W, Cheng A. The PEARLS Healthcare Debriefing Tool. Acad Med. 2018, 93(2), 336.

The day ended with another storytelling evening. Old friends and new gathered at the Sway Bay in central London to share tears and laughter.

What happens at Storytelling stays at Storytelling!

DFTB go to SMACC

Cite this article as:
Andrew Tagg. DFTB go to SMACC, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.18334

Without SMACC there would be no Don’t Forget the Bubbles. But little did Tessa and I know that despite being at the same conference it would be another four years before we actually met in person at DFTB17 in Brisbane.

Nobody knew what to expect at that first SMACC as we sat in the dark waiting for the conference to begin.  I had just signed up with Twitter and was just excited to be in the company of people who thought the same as me, who were excited to learn, and were using this new thing called #FOAMed. As I am the shy retiring type I barely said hello to people that now, a lifetime later, I would be proud to call friends. Instead, I just sat in the audience and absorbed all the knowledge and positivity that flooded my way.

Flash forward a few years and those friendships, forged online, have grown as Twitter avatars are replaced with real people. No longer am I as shy to go up to someone I have never met in real life and I’m glad others have taken up the challenge too (Andrew and Sarah,  I am looking at you).

Tessa and I feel very privileged to have played some small part in the success of SMACC as we run the very final SMACCmini paediatric workshop. If you couldn’t come along then here are some of the things you missed.

 

Sweet Child O’ Mine (A neonates journey) – Trish Woods

Trish is no stranger to the DFTB ethos and as a neonatologist stopped to make us reflect on one of our basic assumptions – just who is the patient.  Just because our tiniest patients lie in their cribs, helpless, requiring help with all of their daily cares, does not mean that we should not consider them as people. It might be an alien thought to some – that the patient in front of us hears what we say, and how we say it, but they are not just a disease or a problem to be dealt with or the one in pod 3. They are a person with a name.

Seeing the team through the eyes and ears of the patient, Trish helps us enter the sensory (and often-overstimulating) world of the NICU.

Why not take a look at this paper on some of the ways we can start treating the patient and not the disease.

Roué JM, Kuhn P, Maestro ML, Maastrup RA, Mitanchez D, Westrup B, Sizun J. Eight principles for patient-centred and family-centred care for newborns in the neonatal intensive care unit. Archives of Disease in Childhood-Fetal and Neonatal Edition. 2017 Jul 1;102(4):F364-8.

I Want Candy (neonatal pain relief) – Justin Morgenstern

Justin Morgenstern, one of everyones favourite Canadians, has recently relocated to our side of the world and is practicing in New Zealand. Knowing that he is such a fan of evidence based medicine we set him the task of finding out if sucrose is as good as we think it is as an analgesic in neonates.

Here, for your delectation, is his take on analgesia for kids.

I don’t want to spoil his conclusion but this slide might give you just a little clue…

He started by challenging a fundamental assumption – that we can accurately tell whether a neonate is in pain or not. Or, more accurately, he challenged our assumption that we could tell when a medication worked.  We know the limitations of the traditional Wong-Baker Faces scale in older children and most of us probably use some combination of our clinical gestalt and the FLACC (Face/Legs/Arms/Cry/Consolation) score in neonates. But is it some sort of surrogate marker for distress, rather than pain? If fMRIs show no difference in an infants brain when they receive sucrose does that mean it does nothing for pain?

Of course there are a lot of things we can do that we know do work:-

  • Limit painful procedures
    • If venipuncture is less painful than a heelprick why not use it.
  • Let nurses treat the pain
    • Nurses are amazing (full stop) but they are also so much better at giving analgesia by the clock than any doctor
  • Address the underlying issues
    • Splint the obviously broken arm  before x-ray rather than waiting for them to get some imaging and then feeling guilty about it.
  • Consider non-pharmacological adjuncts
    • Dogs, clowns and bubbles are all powerful distractors.

 

Straight Up (bilious babies) – Camille Wu

Camille Wu last spoke for us at DFTB17 on testicular tribulations so it was a pleasure to welcome her back to join us to talk about surgical causes of bilious vomiting.

Rather than put words in a parents mouth she suggested asking exactly what colour was the vomit. If they answer Pantone 2565C then you are in trouble. Green vomit suggests a higher up obstruction that might require surgical intervention and certainly requires surgical assessment. Likewise rather than asking if the vomit was projectile, it is better to ask “How far did it go?

Whilst it is important to remember that there are a number of significant medical causes of bilious vomit (such as sepsis and CPAP belly) we really need to be concerned about surgical causes. Camille broke these down into mechanical causes and functional causes.

Mechanical causes

Intrinsic

  • Duodenal atresia
  • Small bowel atresia
  • Ano-rectal malformation

Extrinsic

  • Malrotation/volvulus
  • Congenital bands
  • Intestinal duplication

Functional causes

  • Hirschsprung disease
  • Meconium ileus/plug
  • Necrotising enterocolitis

The more proximal the obstruction the less bubbles of gas you will see on initial imaging. Camille reminded us that early imaging and intervention can make all the difference. If in doubt, pick up the phone, no matter the time of day or night.

The Safety Dance – Linda Durojaiye

Linda Durojaiye is a staff specialist at Sydney’s Children’s Hospital at Randwick. In her talk on leadership and patient safety she owned up to mistakes that have been made and shared some lessons from her department on how they have created a safer environment where everyone is accountable. Given that we have no control over who comes in we need to take ownership of what happens to them once they pass through our doors.

Linda and her team created a culture of safety – starting with regular team huddles to identify potential threats to safety. Using a strong leadership team they created a model of care that engaged both medical and nursing staff as well as the patient/parent consumer. She highlighted the resources freely available on the Institute for Healthcare Improvement website.

If you want to know more about the Clinical Emergency Response System then you can find it here.

 

One Vision (VR in paediatrics procedures) – Andy Weatherall

If your idea of virtual reality is still stuck in the last century and The Lawnmower Man (a poor 34% on Rotten Tomatoes) then you might not be aware of some of the advances that are putting the technology in the hands of normal people. Andrew Weatherall is the co-chair of paediatric anaesthesia at the Children’s Hospital at Westmead and has been looking at the role virtual reality may play as an adjunct to standard anaesthesia techniques.

He has written about his experiences here. Whether as a means to reduce anxiety before a procedure or as a distraction from the procedure itself virtual reality is no longer priced out of possibility. With Google Cardboard costing just a few bucks and lots of open source software available it won’t be long before we see more departments trying it out. We hope to hear more from Andrew and his team in the near future to see how they are going.

The Model (3D printing in paeds) – Jasamine Coles-Black

Carrying in on with technological advancements in paediatrics Jas Coles-Black from the 3D lab at the Austin in Melbourne made the audience realise just how affordable 3D printing can be. A technology that once cost six figures is now cheaper than the average consultants coffee habit. After a quick jaunt through the various methods of printing she went through some of applications relevant to paediatric practice. With printable task trainers costing just a couple of dollars (after the capital expenditure) we could all have our own paediatric can’t intubate – can’t oxygenate model. Or perhaps you want your trainees to learn how to ultrasound the neonatal spine to improve their success at lumbar puncture – a task trainee is yours for less than a latte.

3D printing can also be used to help patients understand complex ideas and a number of cardio-thoracic surgeons have used 3D printed models of congenital heart defects to help explain complex anatomy. We are looking forward to hearing more from Jas about this exciting technology and how it can benefit all of us. And, if people are interested, we could create our very own DFTB 3D printing workshop at a future conference.

Jas' favourite 80s movie

https://www.youtube.com/watch?v=1g3_CFmnU7k

(Yes – I know it was 1977 – Ed)

Sound and Vision (Critical care ultrasound) – Tom Rozen

SMACCmini was competing against the very practical paediatric ultrasound workshop but we couldn’t make it through without mentioning it at least once. Tom Rozen, intensivist at the Royal Children’s Hospital, used the example of René-Théophile-Hyacinthe Laennec’s (yes, really!) most famous invention, the stethoscope, to demonstrate how medical fashion has changed. A device that once took up an entire room can now fit in your pocket and with ultra-cheap, ultra-portable devices entering the market it will not be long before clinicians can have a device of their very own.

If you want to know what all the fuss is about then why not sign up for one of our pre-DFTB19 workshops.

Too Shy (20 minutes of bottom jokes) – Ross Fisher

Mr Fisher was set the challenge of making talking about constipation interesting and he succeeded. From his opening Limahl tribute to the crowd singalong he soon had us tapping our toes to the 1983 Kajagoogoo classic. He began by asking us to turn to the person sitting next to us and take a bowel history. After a round of sniggers a fair percentage of the delegates were unable to complete the task. Fortunately I was sitting next to Tessa and we know each others bowel habits intimately. If we are too shy shy to ask a grown up about what they get up to in the toilet no wonder we are pretty awful at asking children. Most children are all smell, noise and little substance in the bathroom so the only way to really find out what they are up to is to ask them, in their own language.

Constipation and its consequences can be stigmatising to a child and so the mindful clinician should sit and listen to the parent and their concerns, without judgement. Treatment can be a long and drawn out affair taking as long to fix as the child has had the problem for.  Take a look at our series on constipation here.

Faith (It takes a team) – Bec Nogajski

The final talk of the morning, by Bec Nogajski, brought it all together and reminded us of the importance of teaming. We’ve all been a part of dysfunctional teams and Bec challenged us to look at our role in the team, not as a passive sheep to be lead around, but as an integral unit with worth. There are many ways of finding out how you might fit in the team – Belbin’s team roles, DISC, Myers-Briggs (INTJ in case you were wondering) – but it is worth considering  that there is no perfect recipe for an effective team.

The team sets the behaviour, what is tolerated and what is not. As David Morrison said, “The standard you walk past is the standard you accept.” So do you check your mobile phone during clinical handover, and allow others to do the same or is this type of behaviour below the line?

 

 

Our eternal thanks, as always, to the SMACC OC throughout the years, especially, Chris, Roger and Oli who made such an impact on four aspiring paediatricians that they decided that they could run their own conference. If you want to see what all the fuss is about then there are still a handful of tickets left for www.dftb19.com in London, this June.

ADC/DFTB Journal Club #3 – January – POCUS vs Pneumonia?

Cite this article as:
Henry Goldstein. ADC/DFTB Journal Club #3 – January – POCUS vs Pneumonia?, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.17878

Diagnosing pneumonia can be tricky. Each year, 1.2 million children under five years of age die from pneumonia. In developed countries, the incidence is 0.05 per person-year. Pneumonia can imply both bacterial or viral, and there is a distinct challenge in differentiating between these given similar clinical and investigative pictures, or even the presence of pneumonia at all.

What about some POCUS? Can we utilise this investigative modality to spot a child with pneumonia?  The paper from Archives of Disease of Childhood featured in our third #DFTB_JC sought to answer this question.

What’s it about?

 

The general sentiment from the Twitter discussion was that making a diagnosis of pneumonia is challenging. More specifically, there’s no reliable way of differentiating between viral and bacterial pneumonia, nor any particularly strong evidence for whom should or should not receive antibiotic therapy.

Most of those actively contributing (including Sarah McNab, Edd B, Damian Roland & Ding online identified the use of clinical skills; with an emphasis on history (of fever, cough) and examination features (pallor, focal chest findings), with the use of chest radiograph (or roentgenogram if you’re feeling formal), to augment or refute this diagnosis.

Blake (@cobra6blake) suggested a 2017 JAMA review article by Shah et al. as a good summary.

 

The authors methodology made sense with respect to answering the stated question regarding the diagnostic accuracy of LUS vs CXR for diagnosing pneumonia, using this approach:

Although there are well established pros and cons for each modality there was a distinct lack of congruity about which modality was the more accurate, including the rates of agreement between both operators. Jessica Wong (@jessicawswong) also identified Dominguez et al.’s related 2018 article in the Journal of Paediatrics and Child Health.

 

Sonia Twigg and Damian Roland identified the intricacies of anatomic pathology, citing the difference between the clinical entity of pneumonia and the pathologic entity of hepatisation (grey vs red); I recommend Robbins’ pathology for a refresher.

 

Both Sonia & Edd B have identified the key challenge with the paper (and frankly acknowledged the next step, nicely summarised by Lassi et al in this Cochrane Review (emphasis mine).

“Pneumonia is an infection of the lungs. In children it is one of the leading causes of childhood deaths across the globe. Pneumonia can be classified based on the World Health Organization (WHO) guidelines. This classification involves assessment of certain clinical signs and symptoms and the severity of disease. The treatment is then tailored according to the classification. For non-severe pneumonia, the WHO recommends the use of oral antibiotics for treatment. However, pneumonia is caused more commonly by viruses that do not require antibiotic management but rather supportive care. On the other hand, pneumonia caused by bacteria needs management with antibiotics to avoid complications. Since there is no clear way to distinguish quickly which organism actually caused pneumonia, it is considered safe to give antibiotics. However, it may lead to the development of antibiotic resistance and thus limit their use in future infections. Thus the question arises as to whether the use of antibiotics is justified in non-severe pneumonia.” – Lassi et al.

 

For me personally, this paper has sought to highlight an emerging utilisation of POCUS; whilst it contributes to – rather than definitively answering – the evidence and understanding around both paediatric pneumonia and the availability and utility of USS & CXR.

So, a short summary of what we’ve discussed;

– CXR is the “Gold standard” Ix, but the clinical diagnosis of pneumonia remains the most accepted, with occasional augmentation via CXR

– LUS vs CXR are roughly comparable, both with flaws regarding isolated accuracy & predictability

– This study hasn’t been designed to inform whom should receive treatment, but it’s what we’d all like to know

– POCUS is an emerging skill set for emergency +/- paediatric providers to consider

Thanks again to everyone who participated in our #DFTB_JC and we hope you will join us again later this month for our next paper, thanks to #ADC_BMJ.

“Drug preparation and administration errors during simulated paediatric resuscitations”

Things will be kicking off on Twitter at UTC 2000hrs, 21/02/2019. with this paper…

Murugan S, Parris P, Wells M. Drug preparation and administration errors during simulated paediatric resuscitations. Archives of disease in childhood. 2018 Nov 9:archdischild-2018.

 

 

If you want to level up your POCUS skills then why not sign up to one of our point of care ultrasound workshops. They are going to take place on the Sunday before DFTB19. Check out the website for more details.