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The 78th Bubble Wrap x Wexham Park Hospital


With millions of journal articles published yearly, it is impossible to keep up.  Our team have scoured the literature, so you don’t have to… or it might spark an interest to go and have a look at the full article.

We have teamed up with the team from Wexham Park ED which has been coordinated by Dr Mohomed Ashraf Vahedna ST6 A&E.

As a Trauma Unit within the Thames Valley Trauma Network, Wexham Park Hospital hosts trainees from across the spectrum of acute specialties. As senior trainees in Emergency Medicine, the reviewers enjoyed appraising these articles, which reflect their individual interests, while seeing an ever-increasing population in a catchment area covering some of the more diverse and beautiful parts of Berkshire, UK.

If you or your team are interested in doing an individual or joint review, please get in touch with Dr Vicki Currie @DrVickiCurrie1 or

Article 1: What predicts parental anxiety in the Paediatric Emergency Department?

Martin, S.R., Hung, I., Heyming, T.W., Fortier, M.A. and Kain, Z.N. (2023). Predictors of parental anxiety in a paediatric emergency department. Emergency Medicine Journal. 40:715–720.

What’s it about? 

A cross-sectional study checked in with the parents of children presenting to a paediatric ED in California, USA, over a 3-month period. The aim was to understand what contributed to parental anxiety, given that 42.5% of parents disclosed significant anxiety.

Poor parental mental health and less energetic children were most associated with higher levels of anxiety. How sick the child was did not appear to play a role.

Two really important patient groups were excluded – those who were admitted to hospital and families who were not fluent in English.

Why does it matter? 

We regularly meet anxious parents. It is important to explain our clinical decisions and address their concerns. Higher parental anxiety is closely linked to higher child anxiety, with studies showing that parental anxiety influences a child’s pain perception during procedures. Anxiety can also affect their recovery and future interactions with healthcare professionals.

Interestingly, this study alludes to a factor we might not often consider – a child’s temperament. Their temperament influences how they experience and interact with their environment. Children with a higher activity temperament are perceived by their parents to tolerate better the ED environment, which in turn eases parental fears. Taking time to bond with a child and make them feel safe may improve parental support and reduce everyone’s anxiety levels.

The other factor highlighted was parental mental health. Consider this and ask about underlying stressors.

Clinically Relevant Bottom Line:

Two risk factors correlated with higher parental anxiety – the parents’ mental health and the child’s temperament.

Armed with this knowledge, you can keep an eye out for those who may be more anxious. Consider adding a screening tool for parental anxiety to your history.

Reviewed by: Dr. Rebecca Kassam

Article 2: How good is lung US compared to a CXR in non-critically ill children?

Edelman J, Taylor H, Goss A, et al Point-of-care ultrasound as a diagnostic tool in respiratory assessment in awake paediatric patients: a comparative study Archives of Disease in Childhood Published Online First: 14 December 2023

What’s it about? 

The authors compared 100 POCUS (Point-Of-Care-UltraSound ) images captured by trained physicians (in FUSIC/CACTUS). They assessed their adequacy in diagnosing and monitoring children ( under 18 years) with suspected lung pathology that also required a chest X-ray (CXR).

100 children were recruited as a convenience sample and analysed. Independent FUSIC or CACTUS practitioners reviewed POCUS images and their findings were compared to a paediatric radiologist reporting on CXRs.

30% of the POCUS scans were normal and had a normal CXR. Of the 70% of abnormal POCUS, 6% identified abnormalities not reported on CXR.

POCUS had a sensitivity of 98.51% (95% CI 91.96% to 99.96%) and a specificity of 87.9% (95% CI 71.8% to 96.6%) compared with CXR.

Any child in the neonatal or paediatric intensive care unit or any child who had been in the hospital for more than 12 hours was excluded.

Why does it matter? 

CXR has been the go-to imaging modality for children with respiratory pathology but is associated with ionising radiation exposure, limiting its usefulness for performing repeated studies.

POCUS offers higher sensitivity and specificity than CXR, and it may provide a diagnosis sooner than is visible on CXR. The paediatric population is more amenable to ultrasound due to lower subcutaneous tissue, decreased depth of image acquisition, and incomplete ossification of the ribs. All of which leads to easier image acquisition. Accredited trainers are currently lacking.

Clinically Relevant Bottom Line:

Lung POCUS, when used in a ward-based setting by appropriately trained members of the paediatric multi-disciplinary team, is highly sensitive and specific compared to standard CXR.

With excellent positive and negative predictive values, it can reduce the need for repeat CXRs in awake paediatric patients, keeping in mind this was a pragmatic study and has some issues with external validity.

Reviewed by: Dr Ellis Callow

Article 3: How good is point-of-care ultrasound in the diagnosis of testicular torsion in children?

Mori T, Ihara T, Nomura O Diagnostic accuracy of point-of-care ultrasound for paediatric testicular torsion: a systematic review and meta-analysis Emergency Medicine Journal 2023;40:140-146

What’s it about?

Testicular torsion is a surgical emergency that can lead to loss of the testis if not diagnosed and treated quickly. Ultrasound by specialist radiologists is over 90% sensitive and specific for testicular torsion in children. This systematic review and meta-analysis sought to evaluate the accuracy of point-of-care ultrasound (POCUS) by frontline clinicians in diagnosing paediatric testicular torsion.

The review included four diagnostic test accuracy studies that reported data on 784 children presenting with acute testicular pain. The index test was POCUS by a clinician. This was compared to a mixed reference standard that included the results of ultrasound by radiologists, intra-operative findings, and clinical follow-up.

Meta-analysis of included studies estimated that the sensitivity of POCUS for testicular torsion was 98.4% (95% CI 88.5% to 99.8%) and specificity 97.2% (95% CI 87.2% to 99.4%).

Only one study evaluated POCUS undertaken by paediatric emergency physicians, with the other three by urologists. It is also not clear what level of training or degree of experience is necessary to reliably distinguish between torsion and other causes of acute testicular pain.

Why does it matter?

Although testicular torsion can have devastating consequences when not recognised promptly, this diagnosis only accounts for 10-15% of children with acute testicular pain. As no single examination finding can distinguish torsion from other causes of testicular pain (such as torsion of the appendix testis and epididymo-orchitis) many children undergo unnecessary surgical exploration.

A quick, safe, and readily accessible diagnostic scan could help identify a cohort of children with testicular pain who do not need to undergo surgical exploration.

Clinically Relevant Bottom Line:

Although surgical exploration is the accepted standard for diagnosing testicular torsion in many countries, this study suggests a potential role for POCUS.

Many clinicians will still favour the definitive test (i.e. surgical exploration), given the consequences of missing a case of testicular torsion.

It is possible that future diagnostic algorithms could include a combination of clinical features and POCUS findings to determine which children should undergo surgical exploration.

Reviewed by: Dr David Metcalfe

Article 4: What predicts a medical visit after a concussion?

Meyer EJ, Correa ET, Monuteaux MC et al. Patterns and Predictors of Health Care Utilization After Pediatric Concussion: A Retrospective Cohort Study. Academic Pediatrics 2024 24 1 51-58

What’s it about?

This retrospective cohort study was conducted in Boston Children’s Hospital and affiliated paediatric outpatient clinics between 2016 and 2019. It recruited 784 children between the ages of 5 and 17 diagnosed with a concussion either in the ED or in primary care. The authors looked at attendance six months before and after a concussion and determined what factors were associated with re-attendance.

There was a significant increase in all-cause representation to services in the 28 days after concussion. Before injury, children attended services on average 17 visits/1000 patients/day. In the 28 days after, this rose to 83 visits/1000 patients/day (p <0.001).

Factors significantly associated with re-attendance in the six months after injury included being on public insurance – more common among those of lower socioeconomic (SE) status, having a higher baseline number of attendances, and being previously diagnosed with depression/anxiety.

A history of headache disorders was also significantly associated with prolonged concussion-related healthcare (>28 days after injury).

Why does it matter?

Concussion is a common presentation. Understanding which patients might be more likely to re-attend means we can provide specific guidance to these patients and provide reassuring and appropriate follow-up advice on what to look out for.

This may improve healthcare use and allow healthcare providers to refer to appropriate follow-up clinics in specific cases.

Clinically Relevant Bottom Line

Children with multiple previous ED attendances, those of lower socio-economic status, and those with headache disorders and mental health problems are all more likely to re-attend following a concussion.

Consider discharging these patients with specific written advice and detailed safety-netting with their follow-ups planned in either a clinic or their primary health care practitioner.

Reviewed by: Dr. Miranthi Huwae

Article 5: What is the best pre-hospital analgesic in children?

Abebe, Y., Hetmann, F., Sumera, K. et al. The effectiveness and safety of paediatric prehospital pain management: a systematic review. Scand J Trauma Resusc Emerg Med 29, 170 (2021)

What’s it about?

This systematic review looked at the preferred analgesia for young people under the age of 18 with acute pain in. the pre-hospital setting. The authors looked for common agents and their ability to reduce pain as well as any associated adverse events.

Both intravenous (IV) and intranasal (IN) fentanyl were as effective as morphine.

Methoxyflurane (which is not licensed in the UK for those under 18) was effective at reducing pain, but there was conflicting evidence around whether it is better than morphine, fentanyl or other drug combinations.

The effectiveness of ketamine wasn’t examined, though it was safe at analgesic doses. 

There was no evidence that a combination of medications was more effective than fentanyl or morphine alone.

There are a number of limitations, given that data was often extracted from retrospective chart reviews. NSAIDs, paracetamol, Entonox, and nerve blocks were not included.

Why does it matter?

Why should in-hospital clinicians care about pre-hospital drug choices? Well, we want many of the same things from our analgesia – it should be speedy, safe, and efficacious. Unsurprisingly, we also experience some of the same challenges; IM is painful, and IV access might be challenging.

Prehospital pain has implications for pain assessments in our emergency department. Effective pre-hospital analgesia contributes to timely ED analgesia, and not having adequate analgesia can contribute to anxiety and poorer outcomes.

Clinically Relevant Bottom Line:

IN fentanyl and morphine seem comparable and appear to be the drugs of choice due to ease of administration, short duration of action, and excellent safety profile – bearing in mind that paracetamol and ibuprofen were not looked at on their own.

Any analgesic agent is better than none!

Reviewed by: Dr Emma Maxwell

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 our reviewers who have taken the time to scour the literature, so you don’t have to.

All articles reviewed and edited by Vicki Currie and Dr Mohomed Ashraf Vahedna


  • Vicki is a Paediatric Registrar in the West Midlands in the UK , starting PEM in September 2021. Vicki 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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