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The 72nd Bubble wrap x Birmingham Children’s Hospital Emergency Department


With millions of journal articles published yearly, it is impossible to keep up.  

This time we have our first group of colleagues from Birmingham Children’s Hospital Emergency Department. BCH ED is a busy paediatric major trauma centre tertiary ED in the West Midlands and the workplace of Vicki Currie, BW lead and editor.

Article 1: Does giving intranasal fentanyl in ED for vaso-occlusive crises increase the chance of discharge from ED?

Rees, CA, Brousseau, DC, Ahmad, FA, et al. Intranasal fentanyl and discharge from the emergency department among children with sickle cell disease and vaso-occlusive pain: A multicenter pediatric emergency medicine perspective. Am J Hematol. 2023; 98( 4): 620- 627. doi:10.1002/ajh.26837

What’s it about? 

This retrospective study (retrospective analysis of a cross-sectional study which was conducted as part of a trial) looked at vaso-occlusive pain episodes (VOE) in children with sickle cell disease (SCD) from 20 paediatric emergency departments in North America aiming to assess the use of intranasal fentanyl and if its use increased the odds of discharge from ED from 2015-2016.

Four hundred data sets were included, 54% belonging to female patients. Discharge home from ED was the primary. To include children with more severe forms of SCD, those with haemoglobin SS disease or haemoglobin Sβo Thalassemia were also included.

Only 19% of children presenting with SCD-VOE were given intranasal fentanyl, and only half of the departments used intranasal fentanyl in SCD-VOE at all. Other medications were given; 91% of the children received IV opioids, NSAIDs (IV ketorolac 66%) and oral opioids (25%). 

Intranasal fentanyl was only available at 50% of the sites. The use of intranasal fentanyl resulted in a significantly higher chance that children received parenteral opioids within 30 minutes of presentation.

Those given intranasal fentanyl were less likely to be admitted and had nearly nine times higher odds of discharge from ED compared with those who did not. Additionally, children with lower mean pain scores initially, lower mean pain scores during the visit and overall lower overall morphine equivalent doses had greater odds of discharge from the ED.

When intranasal fentanyl was used, patients were 40 times more likely to be discharged from the ED.

There was variation in fentanyl use across study sites, and opioid use before ED attendance was not accounted for.

Why does it matter?

This study supports existing evidence that the use of intranasal fentanyl improves the time to administration of analgesia for those with SCD-VOE. Despite this, these results suggest that there may be under-use of intranasal fentanyl for these children.

Opioids are the mainstay of treatment. SCD VOE is a medical emergency; helping patients achieve timely pain relief is vital.

Clinically Relevant Bottom Line

Intranasal fentanyl should be considered in children with sickle cell disease presenting with VOE.

Reviewed by: Helen Bates (Undergraduate clinical teaching fellow BCH ED)

Article 2: What is the impact of COVID-19 on attendance to ED for young people with self-harm, attempted suicide and suicidal ideation? 

Madigan S, Korczak DJ, Vaillancourt T, Racine N, Hopkins WG, Pador P, Hewitt JMA, AlMousawi B, McDonald S and Neville R. Comparison of paediatric emergency department visits for attempted suicide, self-harm, and suicidal ideation before and during the COVID-19 pandemic; a systematic review and meta-analysis. Lancet Psychiatry 2023. 10: 342-351

What’s it about? 

During the COVID-19 pandemic, children and adolescents suffered ongoing disruption to their education and their social life. Family stress levels grew due to parental depression, unemployment, domestic violence, and increased alcohol consumption. We continually questioned this impact on children but had no clear data about what was happening during the pandemic.

This systematic review of the literature and a meta-analysis tried to identify whether attendance to the PED for children presenting with attempted suicide, self-harm, and suicidal ideation changed during the COVID-19 pandemic. 42 relevant studies were included, and summary data was extracted.  Relative risks and rates of attendance were calculated. Across the 42 studies, 11.1 million emergency department attendances across 18 different countries. This was the first systematic review and meta-analysis looking at this topic.

There was a reduction in total attendance during the COVID-19 pandemic (rate ratio 0.68, 90% CI 0.62- 0.75). The mean age across the study was 11.7 years. There appeared to be an increase in attendance for attempted suicide (1.22, 1.08-1.37) and a modest increase in suicidal ideation (1.08, 0.93- 1.25). There was limited evidence for a change in attendance for self-harm.

Attendances for suicidal ideation or attempt increased more for girls, whereas attendance for self-harm showed no difference between boys and girls. Self-harm increased in older children (16-17 years was most conclusive) and decreased in younger children. Attendances for suicidal ideation increased in all but the lowest socio-economic group, whereas rates of attendance for self-harm only increased in the higher socio-economic group. There was good evidence for a reduction in all other mental health presentations (e.g. depression, psychosis).

It is important to put these findings into context. In general, ED attendance dropped during the pandemic in many countries. There was a reduction in the absolute number of paediatric emergency department visits for any mental illness. Though in some countries, calls to mental health hotlines increased by around 10-15% (Canada) – this population may have been getting support from the ED.

This data relies heavily on the coding, which we know is not standardized across healthcare sites- and, therefore may not be truly reflective.

Why does it matter? 

The COVID-19 pandemic is, hopefully, a once-in-a-lifetime historic event. It will undoubtedly impact the mental health of our children and young people. We need to be mindful of the long-term effect that the COVID-19 pandemic has had on young people’s mental health and provide care to this vulnerable population.

Clinically Relevant Bottom Line

This study revealed increased presentations of attempted suicide among young people during the pandemic. Other mental health presentations such as depression and psychosis reduced in this population during the pandemic.

Reviewed by: Emma Bagshaw (Trainee Advanced Nurse Practitioner BCH ED)

Article 3: Can we reduce radiation exposure without missing paediatric c-spine injuries?

Douglas GP, McNickle AG, Jones SA, Dugan MC, Kuhls DA, Fraser DR, Chestovich PJ. A Pediatric Cervical Spine Clearance Guideline Leads to Fewer Unnecessary Computed Tomography Scans and Decreased Radiation Exposure. Pediatr Emerg Care. 2023 May 1;39(5):318-323. doi: 10.1097/PEC.0000000000002867. Epub 2022 Nov 30. PMID: 36449686.

What’s it about?

This single-centre study looked at reducing radiation exposure in the under-8 population when assessing for traumatic CSI (cervical spine injury) by modifying the imaging protocol within their CSI guideline. Instead of imaging the cervical spine, the guideline advised focused imaging of C1-C4. Previous evidence suggests that most CSI in children aged eight and younger occurs between the occiput and C4.

Undergoing a CT scan as a young child increases your lifetime risk of radiation-attributable cancer, especially to radiosensitive tissue such as the thyroid. This study aimed to see if a modified screening tool could minimise radiation exposure without compromising the ability to detect cervical spine injury.

This retrospective cohort study compared pre- and post-guideline outcomes. An MDT committee developed the guideline at a level 2 paediatric trauma centre in the USA. Imaging was recommended for patients with high-risk pre-disposing conditions, concerning clinical findings or high-impact injuries. If imaging was recommended, they started with plain X-rays. However, any child going for a CT head would also undergo paediatric spinal protocol imaging of C1-C4. Spinal specialists were then consulted if any spinal injury was identified or if the physical examination remained abnormal despite normal imaging. In these patients, MRIs of the full spine were requested at the surgeon’s discretion.

All paediatric trauma patients aged eight or under screened for CSI at the trauma centre between July 2017 and December 2020 were included. 726 patients were screened and split into cohorts of 273 pre-guideline and 453 after implementation. There were no significant differences between the two cohorts. Mean age and ISS scores were similar between the groups.

Full cervical spine CTs were more common before the guideline (22% pre vs 11% post). CT scans of C1-C4 were more common after implementation. MRI utilisation was similar in both groups (4% vs 4.9%). In total, eleven patients had cervical spine injuries. Ten were injuries between C1-C4 – nine were ligamentous injuries picked up on MRI, and one was C1-C2 subluxation detected on CT scan. One patient with persistent neck pain had a C7-T1 interspinous ligament injury picked up on MRI after a normal CT scan of the whole cervical spine.

Why does it matter?

Although CSI is a rare consequence of blunt trauma, delayed or missed diagnoses can have dire consequences, with mortality as high as 48% in children under eight. Whilst MRI may be more diagnostically accurate (CT is still the most useful initial screening tool to look for the most severe injuries), it is often less readily available, is time-consuming and may require sedation. Children with CSI may have other multiorgan injuries, including to the brain; timely diagnosis is paramount in paediatric trauma patients.

The C spine of children aged eight or younger is anatomically immature and, therefore, susceptible to different injury patterns than that of adults or older children. We also must consider the increased risk of radiation-induced cancers in children who undergo CT, especially in young children going through a crucial time in their development.

Whilst its results are encouraging, they must be interpreted cautiously. This was a single-centre study, with only a small number of diagnosed CSIs. Some of the patients included had undergone imaging before enrolment, and the quality of scans was variable. The use of collars for immobilisation is still included in the study protocol (which we have moved away from in the UK).

Clinically Relevant Bottom Line

This study has certainly highlighted potential areas for improvement compared with the current protocols. There may be a place for more targeted cervical spine imaging in the paediatric population- to reduce the radiation dose. Before guidance can change, more work is needed to determine true injury rates and the number of missed injuries.

Reviewed by: Isobel Lane (Emergency Medicine Trainee)

Article 4: Can we MAP out a site for pleural decompression?

Quinn N, Ward G, Ong C, Krieser D, Melvin R, Makhijani A, Grindlay J, Lynch C, Colleran G, Perry V, O’Donnell SM, Law I, Varma D, Fitzgerald J, Mitchell HJ, Teague WJ. Mid-Arm Point in PAEDiatrics (MAPPAED): An effective procedural aid for safe pleural decompression in trauma. Emerg Med Australas. 2023 Jun;35(3):412-419. doi: 10.1111/1742-6723.14141. Epub 2022 Nov 23. PMID: 36418011.

What’s it about?

This study aimed to identify if the Mid-Arm Point (MAP) method of identification of a safe site for thoracic decompression in adult trauma patients could be applied to the paediatric trauma population.

392 children were recruited into this prospective study at one of four participating Emergency Departments.  They were between four months and 18 years old and had a chest x-ray as part of their routine medical/surgical management plan.  Before the x-ray, the MAP (halfway between acromion and olecranon) was measured, and the chest wall was marked at the corresponding level just anterior to the mid-axillary line, bilaterally where possible (712 markers sited). A metal ball was secured at this point to be identified on the subsequent X-ray. A consultant radiologist at each site reported where the marker sat.

83% of markers were within the ‘safe zone’ (4th – 6th ICS) when sited with the MAP technique.  The study team noted that an age-specific adjustment, of one ICS above the MAP, for children aged ≥ four years of age made a significant difference in identifying the ‘safe zone’ – the Mid-Arm Point in PAEDiatrics (MAPPAED) rule.

Why does it matter?

Traumatic injury is the foremost cause of death in children worldwide, with traumatic brain injury identified as the leading cause.  However, previous studies have also demonstrated that children with severe thoracic trauma are ten times more likely to die from their injuries.

Failure rates of needle thoracocentesis can be as high as 60%.  Therefore, thoracostomy has been widely adopted as the preferred decompression method in adults and children worldwide.  Recalling and identifying anatomical landmarks for safe sites for thoracic decompression can be challenging in the pressurised, time-critical trauma resuscitation environment.

Marking the chest at a level corresponding to the Mid-Arm Point (MAP) is a reliable method to identify a safe site for thoracic decompression in adult patients.

Important limitations: this study involved 392 patients, none of which were injured. It’s important to bear in mind that this is not the population that needs an intervention.

Clinically Relevant Bottom Line

The MAP technique will successfully identify the ‘safe-zone’ for thoracic decompression in nine out of 10 children with the age-based adjustment (in children ≥ 4 years of age), MAPPAED rule, to allow for the difference in arm and chest growth rates.

Children aged <4 years of age use MAP rule without adjustment.

Children aged ≥ 4 years of age use the MAP rule but go up one ICS

Reviewed by: Charlotte Clay (Principal Advanced Nurse Practitioner)

Article 5: Are urine dipsticks accurate in diagnosing UTI in infants <90 days?

Waterfield T, Foster S, Platt R On behalf of Paediatric Emergency Research in the UK and Ireland (PERUKI), et al. Diagnostic test accuracy of dipstick urinalysis for diagnosing urinary tract infection in febrile infants attending the emergency department. Archives of Disease in Childhood2022;107:1095-1099.

What’s it about?

A multicentre (8 sites across the UK) retrospective cohort study looked at the accuracy of dipstick urinalysis for detecting UTIs in febrile infants in the paediatric emergency department. However, the data was taken from the Febrile Infants Diagnostic assessment and Outcome (FIDO) study, which looked at febrile infants under 90 days. The study included 275 infants aged 90 days or less with a fever within 12 months and tested either a clean catch or transurethral bladder catheter urine sample. These results were then referenced to the urine culture results to compare sensitivity and specificity rates.

The mean age of any given febrile infant was 51 days. The presence of leucocyte esterase was the most sensitive dipstick result for UTI (including only trace as positive sensitivity was 0.84 (95% CI 0.69-0.94). Nitrites were the most specific dipstick result for UTI (even a trace) 0.91(95% CI 0.86- 0.94). These numbers only improved when the positivity threshold was increased (+1,+2,+3 on dipstick).

Most of the samples were obtained by clean catch (92%), rather than invasive techniques. This may have reduced the accuracy of urine dipsticks due to higher contamination rates.

Why does it matter?

UTI is the most common serious bacterial infection in infants (80-90%), but they often present with non-specific symptoms such as fever, poor feeding, lethargy and vomiting. The current recommendation is urine laboratory microscopy analysis rather than a dipstick urinalysis. Still, dipsticks are quicker (crucial in infants with UTIs) and can be done where there aren’t 24hr laboratory facilities. Thus, if an infant had nitrites and/or leucocytes on their dipstick, the clinician could reliably treat it as a UTI, which may reduce the need for further investigations/procedures.

Based on these findings, using Siemens Multistix, the optimum point for excluding UTI was leucocytes +1 and for confirming UTI was positive nitrites. This is a moderately sensitive and highly specific test to diagnose infant UTI.

Clinically Relevant Bottom Line

Infants are at high risk of serious bacterial infections, and the quicker they are diagnosed and treated, the better the outcome. Urine dipstick is quick and highly specific for diagnosing UTIs in infants.

Reviewed by: Phillipa Wright (Clinical Fellow)

If we have missed out on something useful or you think other articles are worth sharing, please add them in the comments!

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.

All articles were reviewed and edited by Vicki Currie.


  • Vicki is a consultant in the West Midlands in the UK. She is passionate about good communication in teams and with patients along with teaching at undergraduate and postgraduate level. When not editing Bubble wrap Vicki can be found running with her cocker spaniel Scramble or endlessly chatting with friends.

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