With millions of journal articles published yearly, it is impossible to keep up.
The John Radcliffe Hospital is a major trauma centre with a dedicated paediatric emergency department and a strong track record in emergency medicine research
In the Bubble Wrap, we have focussed on research relevant to paediatric emergency medicine
Happy reading 🙂
If you or your team want to submit a review, please get in touch with Dr Vicki Currie at @DrVickiCurrie1 or vickijanecurrie@gmail.com.
Article 1: Use of blood products in paediatric trauma
Mullan K, McAlister P, McVeigh SM, Jones S, Bouamra O, Lecky F, Mullen S. Blood product use in paediatric trauma: lessons from the TARN data. Emerg Med J. 2025 Sep 24;42(10):662-668. doi: 10.1136/emermed-2024-214397. PMID: 40210465.
What’s it about?
This retrospective observational study examined blood product prescribing practices in paediatric trauma over a ten-year period across England, Wales and Northern Ireland.
TARN data were analysed for all trauma patients under 16 years who received blood products from 2012 to 2021.
The aim was to determine trends in blood product use over time, with secondary analyses examining patient demographics, vital signs, injury characteristics, and mortality.
Only 2.5% of paediatric trauma patients received blood products within 24 hours post-injury, with no significant increase in overall blood product administration over time, and a decrease in use in trauma related to road traffic collisions, from 64% to 52%.
There was a statistically significant increase in administration to those with penetrating injuries from 3% to 22%, and in the age of patients who received blood products. Notably, the population receiving transfusion were found to have consistently normotensive median SBP (115-118mmHg), and HR around 100bpm.
There was no significant change in mortality among patients receiving blood products during the study period.
Why does it matter?
Major trauma is the leading cause of paediatric mortality, with major haemorrhage being the most common preventable cause of paediatric trauma deaths.
There has been little improvement in paediatric mortality following trauma, compared to significant improvements in survival rates in adult trauma patients.
There is growing evidence supporting early, appropriate identification of patients requiring blood products, as well as increased advocacy for the principles of damage-control resuscitation. However, studies of blood product use in the paediatric trauma population remain limited, making it difficult to appreciate current UK practice, whether recent recommendations have affected this or in turn had any impact on mortality.
Clinically Relevant Bottom Line
Blood product use should be considered in all paediatric trauma patients, as per current guidelines, but still remains relatively uncommon and has not varied over time, nor has trauma mortality changed.
It is seen most frequently in older children, those with penetrating trauma and those sustaining injuries from road traffic collisions.
As is well supported by previous literature, blood pressure should not be relied upon to assess volume status or to guide trauma resuscitation in paediatrics.
Reviewed by Dr Suzanne Maton
Article 2: Evaluating POCUS for paediatric appendicitis
McCreary D, Chan N, Miller B, et al. Evaluating the diagnostic accuracy of point-of-care ultrasound for paediatric appendicitis: a UK multicentre observational study. Archives of Disease in Childhood Published Online First: 04 November 2025. doi: 10.1136/archdischild-2025-329440
What’s it about?
This prospective observational UK study across two paediatric emergency departments evaluated the diagnostic accuracy of point-of-care ultrasound (POCUS) performed by Paediatric Emergency Medicine (PEM) clinicians for suspected paediatric appendicitis.
226 children aged between 1 and 16 years with abdominal pain and right iliac fossa (RIF) tenderness on examination were included.
The prevalence of histologically confirmed appendicitis was 12.4% (28/226).
POCUS demonstrated a sensitivity of 0.89 (95% CI: 0.71-0.97), specificity 0.96 (0.92-0.98), positive predictive value 0.76 (0.57-0.88) and negative predictive value 0.98 (0.95-1.00). The appendix was visualised in 36% (82/226) of children by PEM clinicians, including 60 cases in which the appendix was normal.
The authors concluded that POCUS performed by PEM clinicians had high accuracy in detecting paediatric appendicitis, and there was also high agreement between POCUS and radiology-performed ultrasound, with a Cohen’s kappa (k) of 0.87 (95% CI 0.70 to 1.00).
Why does it matter?
Suspected appendicitis in children remains a diagnostic challenge in the paediatric emergency department, particularly out of hours when radiology-assisted ultrasound is unavailable. But what if PEM clinicians added a fast, cheap, radiation-free POCUS scanner to their repertoire of diagnostic tools and relied less on clinical gestalt?
It may lead to the correct diagnosis of early paediatric appendicitis, reduced length of stay in hospital in borderline cases, reduced number of missed or delayed diagnoses, and may altogether avoid negative appendicectomies (currently at around 10% on average in the UK).
Clinically Relevant Bottom Line
This UK multicentre study suggests that, with adequate training, POCUS for suspected paediatric appendicitis can achieve high specificity and negative predictive value, indicating it could be a valuable adjunct to the PEM clinician’s repertoire.
However, limitations such as low visualisation rate and poor generalisability mean we should be cautious about using it alone to exclude appendicitis. Ultimately, more evidence is required before this can be implemented widely across UK PEM departments.
Reviewed by Dr Maninder Bhambra
Article 3: Adverse Events in Ketamine Sedation
Green S, Tsze D, Roback M., Emergency Department Ketamine Sedation: Frequency and Predictors of Critical and High-Risk Adverse Events. Ann. Emerg. Med. 2025 Jun 6:S0196-0644(25)00293-8. doi: 10.1016/j.annemergmed.2025.05.003.
What’s it about?
This is a PSRC registry retrospective cohort study evaluating the safety profile of ketamine as the sole agent for sedation during paediatric procedures in the emergency department setting.
The analysis reviews two decades of data from 12,780 individual ED ketamine encounters to accurately determine the incidence and clinical predictors of two primary outcomes: critical adverse events (life-threatening, such as death, cardiac arrest, suspected pulmonary aspiration, anaphylaxis, unplanned intubation, etc.) and high-risk adverse events (those requiring urgent intervention to prevent deterioration, such as apnoea, complete airway obstruction, laryngospasm, positive pressure ventilation, etc.).
Why does it matter?
This study offers the strongest evidence to date on this topic, with definitive data to resolve longstanding clinical debates.
Its large sample size provides substantial statistical power to accurately evaluate the risk of rare but serious side effects, whereas previous small studies and meta-analyses could only estimate it.
It also tackles key issues in our practice, such as the risks of upper respiratory infections, obstructive sleep apnoea, and concurrent opioid use.
Considering ketamine in isolation as a monotherapy in the ED setting gives an immediately relevant assessment of its safety profile for our daily practice.
Clinically Relevant Bottom Line
The evidence confirms ketamine’s established safety profile in paediatric procedural sedation.
The majority of high-risk events (0.52%, 95% CI) are respiratory in nature and are successfully managed with standard care, while critical events are extremely uncommon (0.016%, 95% CI). Most significantly, we now have evidence-based risk stratification guidelines:
Strong Predictors: A moderate but significant increase in risk is linked to age ≥10 years and concurrent opioid use. This promotes maintaining heightened awareness throughout adolescence and avoiding routine co-administration of opioids.
Non-Predictors: It is encouraging to note that obstructive sleep apnoea, upper respiratory infection symptoms, and ASA physical status (I–IV) were not predictive of complications. This supports the idea that, because ketamine preserves respiratory drive and airway reflexes, it is a safe and dependable option for children with these common comorbidities when compared to other sedatives like propofol.
Reviewed by Sameer Dual
Article 4: The increasing problem with E-scooter injuries
R. Cockburn, T. Gillen, L. Harvey, and R. Kimble, “ Heads Up: A Retrospective Review of Paediatric Trauma Secondary to Electric Scooters at a Tertiary Paediatric Trauma Centre in Queensland,” ANZ Journal of Surgery (2025): 1-7 ,https://doi.org/10.1111/ans.70393.
What’s it about?
This study presents a retrospective review of paediatric patients admitted for injuries following E-scooter accidents in Queensland, Australia. Data were analysed over a 15-year period (2009-2024) to assess the types and severity of injuries, mortality, and the need for surgery. They also analysed demographics, helmet use, length of stay, admission to PICU, and need for rehabilitation. Injuries sustained by e-scooters as the primary rider, secondary rider or pedestrian were included.
64 patients were included in this study, and the number of admissions has increased year on year since 2019. Median age was 13, and 76.6% of patients were male.
They found that the head (including face and neck) was the most commonly injured region of the body (51.6%), with skull fractures being the most common fracture type (40.3%). 34.4% sustained intracranial injury (intracranial haemorrhage or TBI).
64% were not wearing a helmet (in a further 31%, helmet use was not documented).
23% were admitted to PICU, and two children died, both from severe brain injuries sustained while not wearing helmets.
Why does it matter?
E-Scooter use is widespread and increasing in popularity globally. This study highlights the rise in paediatric e-scooter injuries and their status as a public health issue.
Despite regulations, injuries are being seen in children under the legal age and with no helmet use. Campaigns to promote helmet use, monitor and regulate e-scooter use and raise awareness of safety and risk associated with e-scooters will be essential in reducing the healthcare burden. Data from studies such as this one can inform public health interventions and regulations, such as licensing and helmet laws.
Clinically Relevant Bottom Line
E-scooter injuries in children are not trivial—they can cause multiple fractures, head injuries, and frequently require admission or surgery.
Helmet use is critical: a large proportion of injured children (including the 2 fatalities) were not wearing helmets, and clinicians must be advising patients and parents about the benefits of wearing a helmet.
For paediatric trauma teams, it’s important to be aware of e-scooter injury patterns and to be familiar with local and national guidance on the law governing e-scooters.
Reviewed by Lindsey Philip
Article 5: Just how useful are inflammatory markers in infants under three months with a fever
Choa ZX, Raveentheran G, Khoo ZX, et al Prevalence of serious bacterial infections and performance of inflammatory markers in febrile infants with and without proven viral illnes Emergency Medicine Journal 2025;42:721-727
What’s it about?
The authors assessed prevalence of serious bacterial infections (defined as positive blood. Urine, CSF culture) in febrile under the age of 3 months. They also evaluated the performance of commonly available blood tests (WCC, absolute neutrophil count, CRP and procalcitonin) in predicting risk of serious bacterial illness in infants with or without proven viral infection.
This was a secondary analysis looking at infants aged under 3 months presenting to a single centre between December 2017 and 31 July 2022. Fever was defined as a temperature of 38 degrees or higher.
1912 patients were assessed, and 1783 were eligible for analysis. 14.6% of the cohort had a serious bacterial infection, and 36.6% had a proven viral infection. The prevalence of serious bacterial infection was lower among infants with proven viral illness than among those without proven viral illness. CRP > 20 showed the highest sensitivity for the presence of serious bacterial infection in both groups, with and without proven viral infection.
The paper showed that infants with coexisting serious bacterial and viral infections had lower median WCC and absolute neutrophil count than those without proven viral infection. Authors hypothesised that in co-infections the viral marrow suppressive effects may outweigh the proliferative marrow response typically seen in bacterial infections.
Why does it matter?
We see a lot of babies with fever under three months of age, whilst serious bacterial infection is rare it can be devastating if missed. There is a temptation to stop hunting for a source once a viral infection is identified. However, a cohort with co-infection exists and is difficult to identify. Because inflammatory markers were lower in the group with co-infection (owing to bone marrow suppression), it is more likely that physicians will be falsely reassured and serious bacterial infectionwill be missed
Clinically Relevant Bottom Line
Over-reliance on biomarkers risks missing serious bacterial infection in febrile infants under the age of 3 months. Clinicians should continue to use clinical acumen and serial markers if there is concern.
Reviewed by Sarah Reynolds
If we missed 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 for scouring the literature so you don’t have to.
Vicki Currie, DFTB Bubble Wrap Lead, reviewed all articles.