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The 12th Bubble Wrap


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With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Article 1: Can we let children with isolated tachycardia go home?

Wilson PM, Florin TA, Huang G, Fenchel M, Mittiga MR. Is Tachycardia at Discharge From the Pediatric Emergency Department a Cause for Concern? A Nonconcurrent Cohort Study. Annals of Emergency Medicine. 2017 Feb 24.

What’s it about?

This paper, and a similar one from the 10th Bubble Wrap, highlight the shortcomings of using a single observation in isolation to guide management. While this may seem obvious the implicit pressure of litigation and retrospective evaluation of decision making do challenge discharge decisions when there is physiological abnormality.

In this one year retrospective study, over 125 000 paediatric attendances were analysed of whom 8.3% were tachycardic at discharge (defined using the 99th centile from Fleming et al.)

There were increased rates of reattendance (RR 1.3), with need for oxygen (RR 1.8), respiratory drugs and admission (RR 2.0), antibiotics and admission (RR 1.5) or IV with admission (RR 1.4) in tachycardic children compared with those were not tachycardic at the index discharge.

Tachycardic children did not however, have higher admission rates or need for clinically important interventions overall at revisit.

One child required CPR at revisit, but was not tachycardic at discharge from the index visit.

Interestingly, around 90% of children discharged with a heart rate above the 99th centile had this recorded more than half hour prior to discharge. It is unclear whether these were the last medical contacts or whether any interventions occurred subsequently to address the cause of the tachycardia.

Why does it matter?

This paper highlights the importance of context – not surprisingly, children with tachycardia at discharge were more likely to have been febrile, or been treated with inhalers but surprisingly there was no association with pain.  Intervention or revisits are likely to represent the progression of illness. It is therefore important to perhaps reflect on the discharge decision, give clear safety net advice and anticipate the possibility of re-attendance, rather than alter management based on a single physiological observation in a child otherwise assessed as suitable for discharge.

Clinically Relevant Bottom Line

Children with isolated tachycardia at discharge ,in whom serious causes are clinically excluded, can be safely discharged with safety netting.

Reviewed by: Shammi L Ramlakhan


Article 2: Taking it lying down

Julliand S, Desmarest M, Gonzalez L, Ballestero Y, Martinez A, Moretti R, Rivas A, Lacroix L, Biver A, Lejay E, Kanagarajah L. Recovery position significantly associated with a reduced admission rate of children with loss of consciousness. Archives of disease in childhood. 2016 Jan 4:archdischild-2015.

What’s it about?

This prospective study undertaken in 11 European paediatric emergency centres looked primarily at the association between use of the recovery position (RP) by caregivers following Loss of Consciousness (LOC) and subsequent hospital admission.  The study of 533 patients showed there was an independent significant association with use of RP and reduced admission rate (p<0.001).  The likelihood of a child being admitted dropped by 72% if the RP was used although the RP was used in only 26.2% of cases. Other manoeuvres used included shaking, splashing water on the face and blowing on the face.

Why does it matter?

Actual or perceived LOC  is a common paediatric presentation with many parents believing that their child has died or is seriously unwell.

The resuscitation council recommend that the unconscious child who is breathing with a patent airway should be placed in the recovery position.   The caregiver’s ability to recognise that the person is breathing without airway compromise in this study is not clear. Regardless the use of the recovery position in an unconscious child, breathing or not is no doubt better than doing nothing and certainly better than doing potentially dangerous manoeuvres such as shaking.

Clinically Relevant Bottom Line

The study highlights the poor use of recovery position as a basic first aid response by caregivers. As healthcare professionals we are able to have a positive influence on this by educating caregivers prior to discharge and consolidating this with use of a patient information leaflet explaining the recovery position and when to use it.  This would be particularly important in children who suffer with seizures.  Not only could this improve the safety of our patients but reduce admission rates as an added bonus.

Reviewed by: Nicola Goodall


Article 3: You had better watch out…

Park JJ, Coumbe BGT, Park EHG, Tse G, Subramanian SV, Chen JT. Dispelling the nice or naughty myth: retrospective observational study of Santa Claus. BMJ 2016;355:i6355

What’s it about?

This  interesting original UK research looks into whether children in hospital being ‘naughty’ or ‘nice’ influenced visits by Santa Claus and other helpers over the 2015/16 Christmas and new year period. Surrogate markers for ‘naughtiness’ were used based on school absenteeism as well as conviction rates for juniors in the local area. Other variables investigated included contextual socioeconomic deprivation and distance from the North Pole. Overall, appears that Santa Claus has good coverage across the UK in general, with 100% of Northern Ireland paediatric wards being visited, followed by 93% in Scotland, 92% in Wales and 89% in England. There was no correlation found between Santa Claus visiting and naughtiness or impact of distance from the North Pole. Unfortunately it was found that Santa Claus is less likely to visit children in hospitals in areas with lower socioeconomic characteristics. The study also looked at other local superheroes and found that elves, followed by footballers were most likely to visit.

Why does it matter?

This study has a number of important implications. It challenges the traditional understanding of Santa Claus treating children who are ‘nice’ better. However it is unable to determine whether or not illness may be factored into Santa Claus’ algorithm for visiting children as there was no data collection on children out of hospital. This study highlights the need for further investigation as to why there are fewer visits to hospitals with contextual socioeconomic deprivation. It also provides good recommendations for possible avenues for addressing this issue including review of Santa Claus’ contract and hiring of local helpers in disadvantaged areas. Based on the new knowledge this study reveals, a number of popular Christmas tunes may need to be revised in order to  be more accurate. There is also serious concern for what should happen if the general paediatric population gets wind of these findings.

Reviewed by: Grace Leo


Article 4: Is it going to be busy at work this holiday season?

Krinsky-Diener M, Agoritsas K, Chao JH, Sinert R. Predicting Flow in the Pediatric Emergency Department: Are Holidays Lighter?. Pediatric emergency care. 2017 May 1;33(5):339-43.

What’s it about? 

This American group asked an important question – is it busier in the paediatric emergency department on holidays – Thanksgiving, Christmas Day, New Year’s Day – than the rest of the year? My own experience is that is seems to be less busy, but that could be because the staff are in a generally happier mood, there are snacks aplenty and time seems to fly by. The counterpoint  is that new death-dealing Christmas presents (trampolines, quad bikes and Nerf guns) have just been handed to a bunch of sugar enhanced youngsters.

This group from New York looked at the presentations to an urban paediatric ED between July 2006 and June 2013 and categorized the into holiday or non-holiday presentations. They also broke up the presentations into time blocks or ‘tours’. They found that Thanksgiving had fewer presentations (81 vs 92) as did Christmas day (70 vs 90) and New Years Day (82 vs 90). This is data based on one American Paeds ED so may not have great external validity but would be an easy data exercise to do in your ED.

Why does it matter?

It might be too late to volunteer to work the holidays but it might be quite a nice shift if you have to work it.

Reviewed by: Andy Tagg


Article 5: What should you buy the kids this Christmas?

Weingart GS, Glueckert L, Cachaper GA, Zimbro KS, Maduro RS, Counselman F. Injuries associated with hoverboard use: a case series of emergency department patients. Western journal of emergency medicine. 2017 Oct;18(6):993.

What’s it about?

As films go, the “Back to the Future” series are classics and commonly revived at Christmas with Gremlins, Jaws and Raiders of the Lost Ark. I got excited at seeing this particular study thinking I’d missed out on the arrival of the “Hoverboard” (As a youngster I remember injuring myself trying replicate the film scene). Alas the Hoverboard here refers to “a two-wheeled device that can reach speeds up to 16 miles per hour”. It’s not a high volume cause of injury, only 83 cases across 10 EDs over six months but children came off worth than adults. They were more likely to have fractures (46.2%) and a large proportion weren’t wearing helmets.

Why does it matter?

Bicycles, Skate boards, Heelies, Trampolines and now Hoverboards – there will undoubtedly now be a debate between the ‘safety’ brigade and those who believe kids will be kids about whether they should be allowed. As with all mechanised devices, used safely and supervised properly, hoverboards are probably not a bad thing

Clinically Relevant Bottom Line

Life happens. Teach children how to ride responsibly (and given a 78 year old was also injured in this cohort) perhaps adults too…

Reviewed by: Damian Roland


That’s it for this month. Many thanks to all of our reviewers who have taken the time to scour the literature so you don’t have to


About the authors

  • Grace is a Registrar at Sydney Children's Hospital. She loves innovative medical education and paediatrics. She is on the organising committee for the DFTB18 and SMACC conference. Grace is a former internal director of the AMSJ. She enjoys board games, cooking and graphic design.


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