This year I was asked to give not one, but two talks at the Victorian branch of the Australasian College of Emergency Medicine Annual Scientific Meeting. It takes place on the picturesque Mornington peninsula. With specific streams for doctors in training as well as fully fledged FACEMs I have tasked with providing a little bit of a paediatric update. This post will focus on the talk I am giving to the consultant stream.
When you are given the title “Sentinel Papers in Paediatric Emergency Medicine 2017” it’s easy to roll your eyes and think “What a dull topic.” Then I realised that most people probably don’t read or scan through 40+ paediatric journals a month and might not know what has been going on in the world of PEM. Of course the readers of DFTB are a discerning bunch and so have been enjoying our monthly Bubble Wrap updates for almost a year now, so I have had plenty of material to choose from.
With 30 minutes and a personal mission statement to ‘not be boring’ I chose the following 5 papers.
Babl FE, Borland ML, Phillips N, Kochar A, Dalton S, McCaskill M, Cheek JA, Gilhotra Y, Furyk J, Neutze J, Lyttle MD. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. The Lancet. 2017 Apr 11.
Children with seemingly minor head injuries present to the emergency department every day. Whilst it might appear to some of my juniors that I rely on my gut feeling I usually lean heavily on the PECARN head injury guidelines to identify children at very low risk of clinically significant injury. There are two other decision rules out there, though, that are in widespread use – the CATCH tool and the CHALICE tool. Whilst some countries recommend using a specific guideline Australian colleges have not taken this step.
It is important to understand that they are not equivalent. They apply to children of different age ranges, different injury severities and have different outcome measures. Table 1 of the article lists all the points of difference.
So what did PREDICT do?
This was a prospective, multi-centre observational study involving 10 paediatric emergency departments in Australia and New Zealand. All children that presented with a head injury of any severity and who were under the age of 18 years of age were enrolled. Data was then collected on the potential inclusion or exclusion criteria of the three rules, as well as the usual demographic data. Emergency department and hospital management data was recorded and all those patients that did not get neuro-imaging were followed up over 90 days .
How many were enrolled?
In all, 29433 children presented to one of the 10 sites over the study period. 22 524 were eligible for inclusion. 2106 children (10%) underwent a head CT, 4544 (23%) were admitted for observation and 83 (<1%) required neurosurgery.
What were the results?
Each of the three decision rules = PECARN, CATCH and CHALICE – performed well in their own ways. The PECARN rules (plural because there are really two rules – one for under twos and one for over twos) had a high sensitivity (90.7-100%) and missed one clinically significant traumatic brain injury that did not require neurosurgery. CATCH had a much greater sensitivity range (76.2-99.9%) and could only be applied to a relatively small proportion of the population due to the exclusion criteria. CHALICE was really sensitive (96-100%) but missed 31 patients of which 2 required neurosurgical intervention.
So what does this mean to me?
CHALICE is sensitive but I’m going to have to at least double my rate of CT scans if I’m going to use it for very little return. I’m going to continue to use PECARN as my go-to decision instrument. I find that showing worried parents the flow chart really helps them understand the low risk of anything serious. (If anyone wants to develop an even more visually appearing data visualization tool we can use then let us know).
Who to scan by Anna Ings on DFTB
Duel of the Rules by Gareth Hardy over at St Emlyn’s
And if you can’t remember PECARN then take a look at this great ALIEM infographic
Look out for Franz Babl’s talk on the APHIRST trial from DFTB17
Humphreys S, Lee-Archer P, Reyne G, Long D, Williams T, Schibler A. Transnasal humidified rapid-insufflation ventilatory exchange (THRIVE) in children: a randomized controlled trial. BJA: British Journal of Anaesthesia. 2017 Jan 18;118(2):232-8.
Just the thought of intubating a child can make some of us come out in a cold sweat. We don’t do it that often and when we do, it is not without risks. With around 14% of ED intubations complicated by desaturation anything that prolongs the safe apnoea time is a good thing. Whilst there is a great deal of debate on the effectiveness of Ap-Ox in adults the data in children is even more scarce. This was a proof of concept study looking at time to desaturation (SpO2 < 92%) in 48 children undergoing elective procedures in the operating room environment. 24 children underwent standard care (jaw support with no O2) whilst the other 24 had THRIVE applied. Those in the standard treatment group took 109.2 seconds to drop their sats. Those in the THRIVE group took 192 seconds.
This has led the way to the Kids THRIVE trial which is currently actively recruiting across Australia. The researchers aim to take the technology out of the operating room and down to the emergency environment (and PICU) and assess its effectiveness in a real world setting.
We covered this paper in the 3rd Bubble Wrap.
Cronin JJ, McCoy S, Kennedy U, an Fhailí SN, Wakai A, Hayden J, Crispino G, Barrett MJ, Walsh S, O’Sullivan R. A randomized trial of single-dose oral dexamethasone versus multidose prednisolone for acute exacerbations of asthma in children who attend the emergency department. Annals of emergency medicine. 2016 May 31;67(5):593-601.
I hate taking medications. I’m rubbish at it and gag on a single paracetamol. If there is ever anything I can do to reduce the number of tablets that I have to take then I will do it. Cronin et al. randomised 245 children (between the ages of 2 and 16) to take either a single dose of 0.3mg/kg dexamethasone or 1mg/kg of prednisolone for 3 days. They then looked at the Paedatric Respiratory Assessment Measure (PRAM) at 4 days.
What is the PRAM score?
The PRAM score is a 12 point scoring system that combines a number of clinical examination findings to determine the severity of an asthma attack.
What was the outcome?
There was no discernible difference in PRAM scores 4 days after the index visit leading the authors to conclude that a single dose of dexamethasone was not inferior to three days of prednisolone. This has certainly been looked at before. A 2014 paper in Paediatrics by Keeney et al. performed a meta-analysis of the available data and found 2 doses of dexamethasone were not inferior to 5 days of prednisolone.
So this trial, coupled with previous data means I am going to start prescribing a single dose of dex for my mild asthma exacerbations that come into the ED.
We covered this paper in the 9th Bubble Wrap.
Why don’t we use dexamethasone for children’s asthma? by Niall Morris at St Emlyns
Dexamethasone for asthma by Sean Fox at Pediatric EM Morsels
Single dose dexamethasone by Alli Boyd at RebelEM.
Kaufman J, Fitzpatrick P, Tosif S, Hopper SM, Donath SM, Bryant PA, Babl FE. Faster clean catch urine collection (Quick-Wee method) from infants: randomised controlled trial. BMJ. 2017 Apr 7;357:j1341.
Over my lifetime I must have spent hours just waiting for children to provide urine samples. And just when you think it is going to happen the dad (and it is always the dad) blinks or turns away and misses the opportunity whilst the child misses the pot. Non-invasive methods of bladder stimulation have been suggested before but Kaufman et al. have taken a real world problem and turned it to their advantage.
What is the technique?
Jono explains the Quick-Wee method.
If you have ever changed a nappy you may have noticed that the mere act of getting a wet wipe out and cleaning the perineum seems to be enough to the flow of urine. They randomised 353 children to the standard watch and wait versus gentle suprapubic stimulation with gauze soaked in saline.
Does it work?
When children (less than a year of age) were left to their own devices only about 12% ‘performed’ within 5 minutes. When the Quick-Wee technique was used 31% of infants did the deed. This gives an NNT of just 4.7. Compare this with the NNT for antibiotics for pain reduction in otitis media of 16. Next time I’m after a urine sample I’m going to give it a go.
We covered this method in the 6th Bubble Wrap
Urine collection by Andy Tagg on DFTB
The Quick-Wee method journal club by Natalie May over on St Emlyns
Wee are the Champions of Paediatric Urine Samples by Ken Milne and Nat May over at the SGEM
Trick of the Trade: Urine Collection in Neonates by Salim Rezaie over at ALIEM
Urine Trouble by Tim Horeczko of the PEM Playbook
Kildare CA, Middlemiss W. Impact of Parents Mobile Device Use on Parent-Child Interaction: A Literature Review. Computers in Human Behavior. 2017 Jun 5.
It is hard to keep up with the paediatric literature. In order to scan through the literature I use a variety of electronic devices – my phone, an iPad and my laptop – at various times of day. I try and only pick them up when the girls are in bed as I’m sure having my face glued to a screen cannot be good for them. This narrative review from the appropriately titled Computers in Human Behaviour asks the question for me. By using the search terms parent, child, mobile device and interaction the authors found 27 articles dealing with the topic.
What were the main themes?
Most parents reported using their phone whilst supervising their children and levels of engagement and interaction dropped off during these periods. Whilst correlation does not indicate causation there has been an increase in injures in young children after the introduction of the 3G phone network. Perhaps the parents that are absorbed in mobile use are less responsive to their kids, fail to respond to negative behaviours and thus children take more risks.
My favourite paper by Harmon and Mazmanian broke parents into four distinct types – the multitask master, distracted addict, authentic human and technological Luddite. If you are not the multitask master then perhaps you might need some help (take a look in the Further Reading section below).
Ring-Xiety and how to unplug by Henry Goldstein on DFTB
Also, check out this Medical Calculator which predicts clinically significant head injuries in children. From PediatricOncall:- https://www.pediatriconcall.com/calculators/catch-canadian-assessment-of-tomography-for-childhood-head-injury-rule-calculator
Great talk and thank you so much.
I’ve been inspired to talk about concussion at a “Lessons Learnt” session at local ED teaching on Wednesday. (I had a moderate head injury in my late 20s and was discharged home post-normal CT, with no written advice, and verbal advice was given to my friend who is an artist, not a doctor – she dropped me home, I woke up the next day with no recollection of events, or any advice and my friend didn’t really understand what had happened either! It certainly changed the way I approach discharging head injured/concussed patients home). I’ll be running a discharge scenario OSCE as part of the session.
Also stumbled across this resource pack in my google travels:
Great resources for AFL families, reinforces a lot of what we already say about respecting concussion and return to sport. I will certainly be using it now as well!
(and I’m doubling down this comment on Franz’ DFTB talk link).
P.S. Paper 5 / Still Faces video was brutal but excellent food for thought thank you!
Thanks again Andy, as ever this is a beautifully distilled product.
At present I’d be inclined to resist a change from pred to dexamethasone in asthma, but not due to any issues with the data or its collection, but in integration of our asthma management strategies with those in primary care.
The bulk of asthma in Australia is managed by GPs and smaller hospitals. At present these places often have no access to oral liquid dexamethasone formulations. I think there is value in having consistencies in our plans, partly to avoid confusion for patients, but also so that parents don’t feel like they are getting an ‘upgrade’ in their care by accessing secondary/tertiary hospitals with minor/moderate asthma.
I think we’ve achieved this in the past by moving from nebulised salbutamol to metred-dose inhalers. To the same end i usually omit ipratropium for burst therapy unless it is clearly needed, to build consistency with asthma action plans.
There may well be individual cases where it’s a good idea of course – eg as in the original paper when you think someone is unlikely to fill a script, or in a medication-hater as you allude to