When a medical student starts their paediatric ED rotation they need to know three key illnesses and that will cover the majority of patients that they see. To round out the ABC trifecta of asthma and crapping (acute gastroenteritis) we have bronchiolitis. At #DFTB19 Ed Oakley from PREDICT gave us the latest.
DoodleMedicine sketch by @char_durand-done live from Australia via the DFTB19 streaming video link!
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.
Cite this article as:
Team DFTB. PREDICT: from knowledge generation to knowledge translation – Meredith Borland at DFTB19, Don't Forget the Bubbles, 2020. Available at: https://doi.org/10.31440/DFTB.21930
Meredith Borland is the current chair of PREDICT and is well-known for her work on the use of steroids in croup. The aim of PREDICT is not just to generate multi-centre research but also to share it and measure its impact. That is where DFTB comes in.
One of the key pieces of work that has informed a lot of Australian practice over the last few years is the CRIB study.
Oakley E, Babl FE, Acworth J, Borland M, Kreiser D, Neutze J, Theophilos T, Donath S, South M, Davidson A, Paediatric Research in Emergency Departments International Collaborative (PREDICT. A prospective randomised trial comparing nasogastric with intravenous hydration in children with bronchiolitis (protocol) The comparative rehydration in bronchiolitis study (CRIB). BMC pediatrics. 2010 Dec 1;10(1):37.
By challenging the long held belief that children with bronchiolitis should get an IV they have saved many of us countless hours.
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.
The Bubble Wrap is our monthly round up of some of the interesting papers that have made it to press. It’s impossible to keep up to date with every publication that comes out but at least you might be a little bit wiser.
Given that DFTB18 was held in Melbourne it was important to highlight the work of PREDICT (the Paediatric Research In Emergency Department International Collaborative)* This talk, by Stuart Dalziel, centred around ConSEPT and the management of convulsive status epilepticus.
Cite this article as:
Tessa Davis. Delayed presentation of head injuries – should we be worried?, Don't Forget the Bubbles, 2019. Available at: https://doi.org/10.31440/DFTB.17874
We have a clear algorithm for when to CT children who present with head injuries immediately after the injury. But, when children present more than 24 hours after an injury, we aren’t really sure what is best practice. This paper, by the PREDICT group, look at the rates of traumatic brain injury in this patient group.
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
Why is this study needed?
We have a range of decision rules to help guide us for children presenting immediately after a head injury. PECARN and CATCH clinical decision rules specifically exclude children who present with a head injury more than 24 hours after the injury. CHALICE doesn’t specifically exclude this group, but there is no published data on this group of patients.
What we worry about is missing a traumatic brain injury, and in particular one that will need surgical intervention. If a child presents after the initial 24 hours, are they more likely to have a traumatic brain injury and should we therefore have a lower threshold to CT scan these patients?
This is a really common dilemma in Paediatric Emergency, and in my own experience, most people have a lower threshold for scanning children presenting late with head injury concerns because of the lack of guidance and evidence in this group.
The authors’ aim is to look at the prevalence of traumatic brain injury in this group, and to identify any factors in these patients that would make a traumatic brain injury more likely.
Who were the patients?
This was a secondary analysis of an existing cohort – the Australian Paediatric Head Injury Study cohort. This was children with a head injury who presented to one of ten paediatric EDs in Australia/New Zealand over a 3.5 year period.
For this secondary analysis, the cohort was split into those presenting within 24 hours, and those presenting later than 24 hours after the head injury. 5% of the cohort presented >24 hours after the injury.
Children were excluded if they had GCS<14, and were also excluded for representations of the same injury.
The original APHIRST cohort included 20,137 head injury presentations.
352 were excluded due to GSC<14 and 20 were excluded due to unknown time to presentation.
Of the 19,765 left, 981 children presented >24 hours after the injury.
Traumatic brain injury on CT (TBI) – intracranial haemorrhage or contusion, cerebral oedema, traumatic infarction, diffuse axonal injury, shearing injury, sigmoid sinus thrombosis, signs of brain herniation, midline shift, diastasis of the skull, pneumocephalus, and depressed skull fracture.
Clinically important traumatic brain injury (cTBI) – death, intubation >24 hours, neurosurgery, or a traumatic brain injury-related admission to hospital of two or more nights.
What were the authors looking at?
The paper examined any associations between a delay in presentation and the mechanism of injury.
It also looked at the injury characteristics and demographics for patients presenting within and after 24 hours of the injury.
Who presented more than 24 hours after a head injury?
Those presenting >24 hours after the injury were significantly more likely to have had a non-frontal scalp haematoma, headache, vomiting, and assault with non-accidental injury concerns.
Loss of consciousness and amnesia were more likely to present within 24 hours of the injury.
Were the late presentations more likely to have a head CT and a brain injury than those presenting within 24 hours?
203 of the 981 patients had a head CT in the late group. This is 20.6% compared to 7.9% in the early presentations.
37 of these children had a TBI on head CT. This is 3.8% compared to 1.2% in the early presentations group. The most common injuries were a depressed skull fracture, intracranial haemorrhage, or contusions.
Eight children had a cTBI (0.8% – which is the same as in the early group) and two required neurosurgical intervention (also not significantly higher than in the early group).
Who were the eight children with clinically important traumatic brain injuries?
The children ranged from six months to 15 years.
Five of them had a low-level fall (<1 m) – one of these required neurosurgical intervention
One was struck by a high speed object
One sustained a blunt injury with a bat during sport – required neurosurgical intervention
One fell out of bed more than two days earlier
Of note in the late group…
No children with amnesia had a traumatic brain injury on head CT
Suspicion of a depressed skull fracture and a non-frontal scalp haematoma were significantly associated with a cTBI
No children with loss of consciousness had a cTBI
What can we take from this?
There may be many reasons why our scanning rate in delayed head injury presentations is so much higher – including the lack of previously existing evidence, and our clinical concern that a TBI is more likely if the symptoms are persisting.
The authors conclude that presenting >24 hours after the injury (with a GSC>14), significantly increases the risk of a TBI. Suspicion of depressed skull fracture or a non-frontal scalp haematoma increase the risk of TBI and cTBI in this group.
Commentary from Damian Roland:
This is a useful sub-analysis of a very good research data set prepared by the PREDICT group which has good face validity and is likely to be externally reproducible in other developed nations.
The question I ask myself when reviewing head injury patients with a ‘delayed’ presentation is ‘why are you delayed?’. The sheer size of this data set is testament to the fact that lots of children present to Emergency Departments because of parental concern following a fall or blunt trauma. If a parent chooses not to present initially it’s usually because they thought the injury was not that significant (not a very high bar to reach usually!) and symptoms have evolved or perhaps the initial circumstances weren’t clear or un-witnessed. For the former case this ‘evolution’ of disease is (not surprisingly) significant. The ‘delayed’ group more likely to demonstrate relevant pathology because the symptoms that pathology were producing were becoming more apparent. For the latter “historical’ muddying is either sinister (note the relationship with non-accidental injury concerns) or perhaps critical information which may have resulted in earlier attendance has been missed.
It is important to note that while the post 24 hour group demonstrated increased risks for many features and outcomes, the absolute numbers are still low. Just because you present 24 hours down the line doesn’t mean do a CT. Just think that bit more carefully than if the child had presented straight after the injury. As this same group have also recently shown, our individual decision making capacity is probably just as good as any rule so we can still trust our own clinical judgement
Up to 48% of infants admitted to Australian hospitals with bronchiolitis receive treatment that has no evidence of benefit. Bronchiolitis remains the most common reason for admission to hospitals in Australia and New Zealand for infants, and yet our practice in treating these patients remains variable. The PREDICT network have conducted a systematic review to produce Australia’s first bronchiolitis guideline based on a robust systematic review. These guidelines broadly agree with the American Academy of Pediatrics and NICE guidelines.
The authors have produced 22 recommendations based on their robust evidence review. Let’s take a look at their key recommendations.
What investigations should we do?
Routine blood and urine testing is not recommended.
Viral swabs are not recommended (although the authors mention that further study needs to be done to determine the benefit of cohorting in wards i.e. when all babies with the same virus are put in the same bay together to avoid spread).
The authors note that in infants under 2 months old with bronchiolitis there is an increased risk of a concurrent UTI.
Therefore in babies under 2 months old with pyrexia, likely bronchiolitis but some clinical uncertainty – send a urine for m, c, & s
What treatments are effective?
Salbutamol – there is no benefit in using salbutamol in infants with bronchiolitis (and some evidence of adverse effects)
Nebulised adrenaline – no benefit
Nebulised hypertonic saline – there is weak evidence of a reduction in length of stay of 0.45 days. However when two studies were removed, both of which used a different discharge criteria than most hospitals, there was no benefit. This is not recommended routinely, although the authors suggest that it should be used only as part of an RCT
Glucocorticoids – no benefit
Antibiotics – not recommended
The risk of a secondary bacterial infection is very low, and there is potential harm from giving antibiotics
Oxygen – no evidence of benefit in infants with no hypoxia, and low level evidence that maintaining the sats over 91% with oxygen actually prolongs the length of stay. There are no reports of long-term adverse neurodevelopmental outcomes in infants with bronchiolitis, however there is also no data on the safety of targeting sats <92%
Commence oxygen therapy to maintain sats over 91%
Sats monitoring – there is moderate evidence suggesting that continuous sats monitoring increases the length of stay in stable infants
High flow – there is low to very-low level evidence of benefit with high flow
Chest physiotherapy – not recommended
Saline drops – routine saline drops are not recommended but a trial with feeds may help
Feeds – both NG and IV are acceptable routes for hydration
This is the first robust Australasian acute paediatric guideline on bronchiolitis. It provides clear guidance for the management of patients seen in Australasian EDs and general paediatric wards with bronchiolitis and is in line with US and UK recommendations. Our current practice often deviates from this evidence-based, and hopefully these guidelines will start the shift towards unifying evidence-based practice in managing infants with bronchiolitis.
American Academy of Pediatrics Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics 2006; 118: 1774–93.
Ricci V, Delgado Nunes V, Murphy MS, Cunningham S; on behalf of the Guideline Development Group and Technical Team. Bronchiolitis in children: Summary of NICE guidance. BMJ 2015; 350: h2305.