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Intubation Of The Critically Ill Child (Tutorial Reading 2)

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Intubation Of The Critically Ill Child (Tutorial Reading 2)

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This post accompanies the talk I was asked to give to a fantastic group of Ambulance Victoria paramedics. I was given the title "Everything you NEED to know about paediatrics" but given that I don't know everything I need to know yet I thought I would drill down and focus on doing one thing well.

One of the biggest challenges is identifying the difference between sick and not sick. In the prehospital environment you don't have the luxury of time and observation. All you can go on is what is in front of you. So how can you distil years of training and exposure? Perhaps what we call gut feeling is really a synthesis of the paediatric assessment triangle - a decision based on one snapshot in time.

The basics

The American Academy of Pediatrics introduced the Pediatric Assessment Triangle - PAT - ( Editors note: I'm going to call it the PAediatric Assessment Triangle throughout this post as I just cannot bring myself to spell it that way. Sorry, Tim) in 2000 in the Pediatric Education for Pre-hospital Providers course. It was an effort to make it easier for pre-hospital providers to triage children into sick or not-sick, and perhaps to help them determine the cause of illness too.

Appearance

So what does that child actually look like? What do we take in at first glance that might make us concerned. Consider this mnemonic.

Tone

Are they unusually floppy, like a ragdoll, unable to hold themselves upright? By six months of age nearly all children should be able to sit up and support their own heads.

Interactiveness

To a newborn child the world is an amazing place, full of strange sights and sounds and smells. Babies have learnt to smile by about two months of age and by a year or so they are following objects around the room with their gaze. If they do not appear to be interested in what is going on in the world around them then it is time to be a little more concerned.

Consolabilty

Children cry - all of the time. They cry because you want to brush their hair, they cry because you don't want to brush their hair, they cry because you have looked at them. But they are also consolable. If they can't be consoled, despite the best efforts of their mother, then something is amiss.

Look/gaze

Whilst staring off into the distance may be normal for a teenager it is probably not normal for a three year old (unless they are very hungry).

Speech/cry

Crying, generally, is good especially of it is someone else's child and not your own, as long as they are consolable (see above). But that high pitched squealing cry, that means something different entirely.

All of these things help make up our clinical gestalt. They are something that we are often not even aware that we are aware of. Taking a look at their breathing may require a little more attention.

Breathing

Assessing their work of breathing does not require an eidetic memory of age-based norms, but once again is a snapshot taken in seconds. Problems can occur at any point of the respiratory tree from snotty nostrils through tightened tracheas and blocked bronchioles. Assessing this is a matter of looking AND listening.

Here are some of the things we are looking for...

But we can take in just as much information through our ears as we can through out eyes.

As air passes through the nostrils on its way to pulmonary alveoli it can be subject to smooth, laminar flow, or the chaotic eddies of turbulent flow. Any point of narrowing in an already small airway can make a sound. I liken it to my my 2 year old trying to breath through a recorder. If I want silence I need to remove the narrow mouthpiece, the part that starts the noise.

As it passes inwards through a narrowed larynx (for whatever reason) we may hear stridor and as it gets to the narrowed bronchial tree of an asthmatic (for example) we may hear a wheeze. If the air hunger is great enough we don't need a stethoscope to hear these noises, you can hear them from the end of the bed. These noises, coupled with the grunt of a child trying to generate enough PEEP to keep their alveoli from collapsing, are the sounds of respiratory distress. In the pre-verbal child, then, there seem to be a number of overlaps with veterinary science.

Circulation

Embarrassment of the circulatory system is much harder to spot.

Often the child needs to be undressed to make these changes a little more obvious. You might want to rely on the capillary refill time too but this is not part of the assessment triangle. It is a strictly no-touch technique.

Once we have a basic snapshot of appearance, breathing and circulation we can combine the elements to help determine both how unwell the child is and what could be wrong with them.

So does it actually work?

Even after 20 years in practice I cannot remember the age-based norms for vital signs (and there is some evidence that the ones we have may not be accurate anyway). I like to think of patients as either sick or not sick, in the first instance. If I feel they are sick then the next question is nearly always why? Does the Paediatric Assessment Triangle framework actually work in real life?

One group from UCLA examined how accurate triage nurses were at using the tool. In their prospective observational cohort they provided a multimedia training package then asked nurses to fill in a PAT card for every child that came through the door that met inclusion criteria. The investigators then performed a structured chart review to assess just how good the PAT was. They found that it did a great job of identifying stable patients ( LR 0.12) but an even better job of determining their pathophysiology.

A similar study was done with EMS providers and had similar results. Paramedics were very good at detecting stability and instability using the tool. Both groups have a degree of medical knowledge and it would be hard to determine how that might bias their assessment. Could non-medics be trained to use the tool? Could a computer?

Limitations

Most of the data only applies to children under 14 years of age and those with what could be termed a normal baseline. It is much less useful in children with developmental delay, those with congenital abnormalities or those reliant on technology to keep them alive.

For an aural version of some of the things covered in this talk you could not do better than listening to Tim Horeczko.

If you enjoyed this post, why not check out our online courses at DFTB Digital

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This post accompanies the talk I was asked to give to a fantastic group of Ambulance Victoria paramedics. I was given the title "Everything you NEED to know about paediatrics " but given that I don't know everything I need to know yet I thought I would drill down and focus on doing one thing well.

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Being labelled as having a penicillin allergy may seem harmless, but for those who fall ill, it increases the likelihood that they will be treated with broad-spectrum, non-penicillin antibiotics, which are linked to a higher incidence of antibiotic resistance and poorer health outcomes.

"Patients with a penicillin allergy record are much more likely to be treated with macrolides, tetracyclines, clindamycin, cephalosporins and quinolones, and some of those are more associated with resistance," explains Jonathan Sandoe, an associate professor of microbiology at the University of Leeds.

"For example, in Streptococcus pneumoniae - one of the most common causes of community-acquired pneumonia - there's much more resistance to macrolides than to penicillins."

Around 10% of the general population claim to have a penicillin allergy, often because of a skin rash that occurred in childhood, and numbers appear to be increasing. An analysis of hospital episode statistic data by The Pharmaceutical Journal reveals that, between 2012/2013 and 2018/2019, the number of hospital admissions in England where the patient had a recorded history of penicillin allergy almost doubled, from 575,000 to 1.1 million.

Patients with a penicillin allergy record are much more likely to be treated with macrolides, tetracyclines, clindamycin, cephalosporins and quinolones, and some of those are more associated with resistance

As a proportion of total hospital admissions in England, those with a history of penicillin allergy rose from 4% to 6% over the same time period.

However, studies indicate that penicillin allergy could potentially be excluded in 90% of cases and, even for those who have had a reaction to penicillin in the past, the risk of allergy wanes over time as allergic antibodies disappear. Just 20-30% of those who have previously reacted to penicillin will do so in the same way ten years later.

The Department of Health and Social Care is calling for a reduction in the use of broad-spectrum antibiotics as part of the UK's five-year national action plan to tackle antimicrobial resistance, and experts say that reassessing and removing penicillin allergy labels where safe to do so, also known as 'de-labelling', could have a significant impact on achieving that goal. This is a complicated area, but there are some who are looking at ways of making de-labelling routine in the NHS.

Impact of penicillin allergy labels

Numerous studies have highlighted the link between penicillin allergy labels and poorer outcomes for patients.

A 2019 study which collected data on penicillin, carbapenem, monobactam and clindamycin usage, and associated adverse reactions, found that Clostridium difficile infection is more common with broader spectrum antibiotic exposures, such as carbapenems or clindamycin.

In 2018, the National Institute for Health and Care Excellence urged healthcare staff to check that only bona fide penicillin allergies are recorded, after research published in the BMJ highlighted that people with a penicillin allergy label were almost 70% more likely to develop methicillin-resistant Staphylococcus aureus and 26% more likely to develop C. difficile
.

"If you look at the evidence around the risks associated with having a penicillin allergy and getting an alternative treatment, [there are] higher rates of resistant infections and a higher incidence of C. difficile [infection]," says Jacqueline Sneddon, an antimicrobial pharmacist, project lead of the Scottish Antimicrobial Prescribing Group (SAPG) and chair of the Royal Pharmaceutical Society's antimicrobial expert advisory group.

"So, there are potential adverse consequences for patients [who receive] an alternative [to penicillin]," she warns.

We know in our hospital that [if you have a penicillin allergy label], your risk of being given meropenem goes up around six-fold

"We know in our hospital that [if you have a penicillin allergy label], your risk of being given meropenem goes up around six-fold," says Neil Powell, consultant antimicrobial pharmacist at Royal Cornwall Hospitals NHS Trust.

Meropenem, a carbapenem, is on the World Health Organization's (WHO's) 'reserve' list of antibiotics that should be used as "last resort" options, while many of the penicillins are on the 'access' list, meaning they are recommended as a first treatment option.

Powell says that penicillin allergy has also been found to increase the use of vancomycin - an antibiotic on the WHO's 'watch' list - which in turn drives the evolution of vancomycin-resistant enterococci.

"So, the penicillin allergy label does drive more second-line or broad-spectrum antibiotic use. These antibiotics seem to be more toxic and are associated with higher treatment failure rates," he adds.

Determining true penicillin allergy

Unfortunately, according to Powell, testing people for 'true' penicillin allergy is a "laborious process" that requires specialist input which is not always available.

"It is meant to be delivered by allergy services - immunologists - but there's no capacity to do that," he explains.

"With an increasing number of patients coming in [with suspected penicillin allergy] and no solution to this problem currently with the immunologists, we need to work out ways of moving this out of immunology and into general medicine - medics, pharmacists et cetera - to try to tackle this."

With an increasing number of patients coming in [with suspected penicillin allergy] and no solution to this problem, we need to work out ways of moving this out of immunology

Testing for a true penicillin allergy starts with an immunoglobulin E (IgE) test. IgE is a class of antibody associated withâ€¯allergicâ€¯reactions and is normally found in very small amounts in the blood, regardless of whether a person has an allergy (see Figure).

Figure: Testing for a penicillin allergy

The majority of people who have a positive IgE result will be confirmed as being allergic and will not undergo any further investigation unless it is clearly indicated. If the result is negative, a skin test will then be carried out, which involves injecting a small amount of penicillin under the skin.

"If the [patient] reacts to [the skin test] quickly, that's likely an IgE-mediated reaction," says Powell. "And then the [immunologist] won't go any further."

"If you have a negative skin test, which the majority [of people] do ... then they would go on to [do] an oral challenge. If the patient doesn't react to the oral challenge then you can [confirm that] they are not allergic to penicillin".

However, Powell adds that it is possible to go straight to a supervised oral challenge for people with a history of a low-risk allergy, such as a delayed skin reaction, without having to do a skin test. This means that penicillin allergy testing could be moved out of immunology and into other areas of the hospital.

Moving away from immunology

In Scotland, Sneddon is piloting a process to de-label penicillin allergy in acute hospitals using an oral penicillin challenge.

"We've developed a risk-based algorithm which helps us to identify which people are at low risk of having a true allergy ," she explains.

The test involves giving low-risk patients a single dose of penicillin and then monitoring them closely to see if they have a reaction. If they fail to have a reaction, this is documented in their notes and communicated to the patient and their GP.

We've developed a risk-based algorithm which helps us to identify which people are at low risk of having a true allergy

"The process involves lots of communication with the patient about the practicalities of the test and the benefit of a negative test," Sneddon explains.

The SAPG aims to launch a national toolkit towards the end of 2020 to help clinical teams in Scotland safely carry out penicillin allergy de-labelling.

Louise Savic, a consultant anaesthetist at Leeds Teaching Hospitals NHS Trust with a special interest in drug allergy and chair of the British Society for Allergy and Clinical Immunology (BSACI) penicillin allergy de-labelling guideline group, says that penicillin allergy is a "big problem" in surgical patients.

"We know that at least 10-15% [of patients] have this label and will [consequently] get second-line antimicrobial prophylaxis in surgery," she explains.

"And that causes us a problem because the second-line antibiotic they get, which is teicoplanin in this country, is quite allergenic - more so than any other drug we give in the perioperative period."

But an even bigger problem, she says, is how this is feeding into antimicrobial resistance. According to Savic, in the surgical population alone, millions of doses of antibiotics are given to help cope with surgical-site infections; if 10% of the population has a penicillin allergy label and are getting alternatives, then that is potentially millions of second- and third-line, broad-spectrum antibiotics that are being given, in most cases, "completely unnecessarily".

"We know that there are all these patients with labels - and we know that the vast majority aren't correct - but we don't have enough allergy specialists to test all of the people in the country."

We know that there are all these patients with labels - and we know that the vast majority aren't correct - but we don't have enough allergy specialists to test all of the people in the country

In Savic's line of work, preoperative assessment clinics are an appropriate place to assess patients with a penicillin allergy label, but some countries, including the United States and Australia, have explored carrying out these tests in emergency departments, inpatient areas and oncology, with some success.

There is also the potential for penicillin allergy de-labelling to be carried out in primary care, but Savic says that views on this are "a bit mixed".

"There's really good evidence in children. They're much more likely to have viral rashes at the time of taking penicillin, so they probably can be de-labelled very safely in the community.

"[But] I think there are some problems with de-labelling adults in the community. The biggest of those is going to be that GPs don't have time to do their day job, let alone take on an additional role," she says. "[Plus,] I'm not totally convinced that it's the safest place for it to be done."

As Savic explains, if you give enough people a challenge test, eventually somebody will have an allergic reaction.

Barriers to de-labelling

In a recent study, Savic recruited more than 26,000 surgical patients and anaesthetists to determine understanding of penicillin allergy and the potential barriers to de-labelling.

"We looked at all the people within that group who had a penicillin allergy label and stratified them into low-, intermediate-, or high-risk of true allergy, based on a detailed history," she explains.

"[We were] trying to work out what the barriers [were, whether] the patients wanted testing, how many would be suitable for a direct [oral] challenge and what anaesthetists thought about the label."

The research highlights that it is clinicians and healthcare workers who might provide the biggest barriers to labelling. "Patients generally want testing, but there's still a lot of anxiety among clinicians," Savic says.

Sandoe is the co-chief investigator on a National Institute for Health Research-funded study, due to end in October 2023, called the ALABAMA (Allergy antibiotics and microbial resistance) study, which aims to find out whether people with a penicillin allergy label in their GP health records really do have an allergy, and if the number of patients wrongly labelled can be reduced.

"ALABAMA is an open-label, randomised controlled trial of penicillin allergy testing in patients in primary care," he explains.

"Patients with a penicillin allergy record who are likely to need an antibiotic in the future are randomised to either carry on usual clinical care or go to an immunology clinic and be formally penicillin allergy assessed [and potentially de-labelled]."

Following randomisation, the researchers will look at how individuals respond to treatment when prescribed antibiotics for a condition where penicillin would normally be considered first line.

"It is a trial of a complex intervention," says Sandoe, speaking in a personal capacity. "It's not just comparing test A with test B, or drug A with drug B, we're actually looking at the whole process of testing as well as the effect on patient health outcomes."

The study has also revealed many of the barriers preventing penicillin allergy de-labelling. These range from overarching practical barriers, including the lack of capacity in the NHS, to local barriers, such as GPs often not referring patients for testing because they are uncertain about the processes involved and how they would interpret the results.

However, as with Savic's findings, there is a willingness to be tested among patients and a willingness to take penicillin if a test comes back negative.

They don't like having this allergy label and they often don't know why it's there

"They don't like having this allergy label and they often don't know why it's there, for example, they were just told that they had a reaction in childhood, so many patients are positive about being tested," says Sandoe.

The literature, he adds, indicates that after excluding patients with anaphylaxis, which has been reported as being less than 1%, more than 95% of people with an allergy record who are tested turn out not to be allergic after all,.

Moving forward

The BSACI, which has wide stakeholder engagement from several royal colleges, plans to produce guidelines later in 2020, which will outline which patients can safely be de-labelled by non-specialists, what methods they should use, and what the safety and training standards should be, in order to encourage more widespread de-labelling.

"I think there's a role for a wide range of people who aren't primary allergy specialists - and that's pharmacy, that's nursing, it's other medical specialties. I don't think this is a problem owned and delivered by doctors alone, it has to be cross specialty," says Savic.

Sneddon agrees that pharmacists should have a major role in the de-labelling process.

"From a pharmacist perspective, the screening element it likely to be their main role ... they could screen to see if the patient is low-risk and then pass on the details to the specialist to make the decision as to whether they want to offer the de-labelling test or not," she says.

From a pharmacist perspective, the screening element it likely to be their main role

As part of his PhD, Powell is trying to assess how to motivate and encourage doctors, nurses and pharmacists to take allergy histories on the ward to help identify those who are at low risk of penicillin allergy and who could be given penicillin under supervision.

"What tools do they need to safely do it, and what reassurance do they and the organisation need to [help them understand that] this is a safe thing to do, [and that] patients are up for it?"

While there are pockets across Great Britain where important work is being carried out in the area of penicillin allergy, this needs to be widespread in order to have a significant impact on improving antimicrobial stewardship and reducing adverse healthcare outcomes.

"The upshot is that we're seeing twice as many patients with this label than we used to," says Powell.

Antibiotic resistance, increased readmission rates and lengths of stay, and admissions to intensive care units are all things associated with penicillin allergy labels, he adds.

"If you think about the creaking healthcare service in terms of volume of patients, we're unnecessarily [adding to this] because of these labels."

Table: Antibiotic allergy classifications

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Dangerous labels: incorrect penicillin allergies fuel antibiotic resistance - The Pharmaceutical Journal

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Being labelled as having a penicillin allergy may seem harmless, but for those who fall ill, it increases the likelihood that they will be treated with broad-spectrum, non-penicillin antibiotics, which are linked to a higher incidence of antibiotic resistance and poorer health outcomes.

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As children have returned to school, we have seen more croup through the ED, so it's time to refresh your memories!

What is croup?

Viral laryngotracheobronchitis. It is essentially inflammation around the main large breathing structures, usually caused by parainfluenza 1 + 3. Other respiratory viruses, including SARS-CoV-2 and RSV, may also be involved. This inflammation causes a tell-tale cough and noisy breathing due to the obstruction to flow. There may be signs of increased work of breathing, too such as sub-costal recession or a tracheal tug. However, they are generally quite well and are running around the waiting room!

Who gets croup?

Many children - roughly 2-3% of all children per year! These kids are usually between six months and four years of age and occur at the beginning of autumn, though this spring, we see a lot of cases. Children with croup may present with a preceding coryza-like illness and a low-grade fever. This then develops into a barking " seal-like " cough and, for some reason, always seems worse at night. Boys are more commonly affected than girls; some children seem to get it yearly.

How do we treat croup?

This depends on your assessment of the child. Croup is a self-limiting viral illness, and treatment tends to look to a short-term reduction in the inflammation to improve the work of breathing. Historically clinicians have used the Westley scoring system to score croup and assess their severity before giving medication.

In children who look unwell, it is important to not upset them by avoiding unnecessary interventions such as excessive handling or performing an ENT exam.

The role of steroids in croup

If the child can take the medication, dexamethasone or prednisolone should be given to all cases of croup where any stridor or increased effort in breathing is present.

Dexamethasone appears to be more efficacious than prednisolone. It has an onset of action within 1 hour (30 minutes - 4 hours) and has a half-life of up to 36-72 hours (Schimmer 2005). There has been debate overdosing with doses of 0.15mg/kg, 0.3mg/kg and 0.6mg/kg of dexamethasone. Ultimately, 0.15mg/kg not inferior to 0.6mg/kg. At the time of writing both NICE and the BNFc recommend 0.15mg/kg as the initial dose of dexamethasone. If there are concerns about re-occurrence patients are occasionally sent home with an additional dose to be taken 12 hours later.

Prednisolone tends to be favoured in primary care at a 1mg/kg dose with two additional daily doses. There appears to be no significant clinical difference between the two different steroids regarding the need for further treatment or length of stay. Dexamethasone was associated with a reduction in re-attendances, which may be due to the shorter half-life of Prednisolone (Gates 2018, Schimmer 2005)

Nebulised budesonide ( 2mg stat dose) is reserved for children who cannot take oral medication. This may be because it was spat out or because they are working too hard to breathe. A Cochrane review in 2018 shows that budesonide is not superior to dexamethasone, with Westley Croup scores better in the dexamethasone group at 6 and 12 hours compared to budesonide. A combination of treatments does not appear to lead to additional benefits (Gates 2018)

The role of adrenaline/epinephrine in croup

In severe cases, when the child has features of severe work of breathing, including significant recession, hypoxia or tiring, nebulised adrenaline has been used ( 0.4-0.5ml/kg, maximum 5ml of 1:1000). Adrenaline provides short-term relief from respiratory distress. It can be a bridge to getting steroids on board. The effects are short-acting and wear off after a couple of hours. It can be repeated every 30 minutes, although if you need repeat doses, anaesthetics and senior colleagues should be involved in this patient's care.

What doesn't work in croup?

In the olden days, parents tried treating croup at home with steam inhalation (ineffective). In hospitals, humidified oxygen has also been tested though this has not been proven effective either (Moore 2007). Heliox (oxygen and helium combined) has also been looked at as it may improve airflow. However, the evidence is limited, and safety and efficacy remain questionable (More, 2018). Finally, there is no evidence that salbutamol works for croup.

They sound better, what's next?

If they are well and the stridor has resolved, patients can be discharged home with safety-netting advice. The effects of dexamethasone should last as croup itself is usually limited to 2-3 days of symptoms. However, parents need to be aware that some symptoms of respiratory distress can return, usually the following night.

Patients may require a prolonged period of observation if:

stridor is still present at rest, or there is increased work of breathing

the child is very young (<3 months)

an adrenaline nebuliser had to be given

there is a past history of severe croup

there is a history of upper airway problems (i.e. laryngomalacia or subglottic stenosis)

concerns about the child returning (i.e. long-distance, social concerns)

When is it not croup?

Epiglottitis - a rare condition thanks to the HiB vaccine. A child would present with sudden onset, fever, drooling and looks unwell, holding the head back and neck extended. This is a medical emergency, and keeping the patient calm is paramount.

Tracheitis- thankfully also rare. It presents with the child acutely unwell after a prolonged course similar to Croup.

Anaphylaxis/allergy - this may be accompanied with angioedema, rash and wheeze, and requires swift treatment with IM adrenaline

Quinsy/retropharyngeal abscess

Foreign body - Usually the history would help suggest this, with a sudden onset history in a well-child.

COVID and croup

Most children admitted into hospitals are now swabbed for COVID. This can provide a challenge - balancing upsetting the child (and making the upper airway obstruction worse) and performing an invasive swab. It is sensible not to swab the child whilst there is still concern about acute stridor and work of breathing.

Some case studies suggest that a small cohort of patients with croup who were SARS-CoV-2 positive are less responsive to the usual treatment (Venn 2020). These cases may need prolonged admission due to a lack of response and the need for additional supportive therapy.

Selected references

1. Al-Mutairi B, Kirk V. Bacterial tracheitis in children: Approach to diagnosis and treatment. Paediatr Child Health. 2004;9(1):25-30. doi:10.1093/pch/9.1.25

2. Garbutt JM, Conlon B, Sterkel R, et al. The comparative effectiveness of prednisolone and dexamethasone for children with croup: a community-based randomized trial. Clin Pediatr (Phila). 2013;52(11):1014-1021.

3. Gates A, Gates M, Vandermeer B, Johnson C, Hartling L, Johnson DW, Klassen TP. Glucocorticoids for croup in children. Cochrane Database of Systematic Reviews 2018, Issue 8. Art. No.: CD001955. DOI: 10.1002/14651858.CD001955.pub4. Accessed 28 April 2021

4. Moore M, Little P. Humidified air inhalation for treating croup: a systematic review and meta-analysis. Fam Pract. 2007;24(4):295-301

5. Moraa I, Sturman N, McGuire TM, van Driel ML. Heliox for croup in children. Cochrane Database of Systematic Reviews 2018, Issue 10. Art. No.: CD006822. DOI: 10.1002/14651858.CD006822.pub5

6. Schimmer B P, Parker K L. Adrenocorticotropic hormone: adrenocortical steroids and their synthetic analogs: inhibitors of the synthesis and actions of adrenocortical hormones. Goodman and Gilman's the pharmacological basis of therapeutics, 9th edition. New York: McGraw‐Hill, 20051459-1485

7. Smith DK, McDermott AJ, Sullivan JF. Croup: Diagnosis and Management. Am Fam Physician. 2018 May 1;97(9):575-580. PMID: 29763253.

8. Sparrow A, Geelhoed G. Prednisolone versus dexamethasone in croup: a randomised equivalence trial. Arch Dis Child. 2006;91(7):580-583. doi:10.1136/adc.2005.089516

9. Venn AMR, Schmidt JM, Mullan PC. A case series of pediatric croup with COVID-19 [published online ahead of print, 2020 Sep 15]. Am J Emerg Med. 2020;S0735-6757(20)30829-9. doi:10.1016/j.ajem.2020.09.034

10. https://www.rch.org.au/clinicalguide/guideline_index/Croup_Laryngotracheobronchitis/

11. https://cks.nice.org.uk/topics/croup/

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As children have returned to school, we have seen more croup through the ED, so it's time to refresh your memories! Viral laryngotracheobronchitis. It is essentially inflammation around the main large breathing structures, usually caused by parainfluenza 1 + 3 . Other respiratory viruses, including SARS-CoV-2 and RSV, may also be involved.

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30 mins pre-course work for Thursday (4/3) session 

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30 mins pre-course work for Thursday (4/3) session 

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Intubation Course | Paediatric Emergencies

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The Paediatric Emergencies Intubation Course is truly multidisciplinary, attracting healthcare professionals of all levels of experience and from a wide range of specialties, providing an excellent opportunity to learn from each other.
Location:
Riddel Hall, 185 Stranmillis Road, Belfast BT9 5EE []

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Intubation Course | Paediatric Emergencies

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The Paediatric Emergencies Intubation Course is truly multidisciplinary, attracting healthcare professionals of all levels of experience and from a wide range of specialties, providing an excellent opportunity to learn from each other. Location: Riddel Hall, 185 Stranmillis Road, Belfast BT9 5EE []

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Immobilizing the cervical spine (dontforgetthebubbles.com)

PECARN: C-SPINE study - developing a risk assessment tool & identifying modifiable health care disparities in children with cervical spine injuries • EIIC (emscimprovement.center)

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Introduction and Basics: (10 mins) pre-reading, glossary of terms, anatomical considerations Main session: (2 x 15 minutes) case discussions covering the key points and evidence Advanced session: (2 x 20 minutes) case discussions covering diagnostic dilemmas; advanced management and escalation Sim scenario (30-60 mins) Quiz (10 mins) Infographic sharing (5

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The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma - PubMed (nih.gov)

PECARN Pediatric Head Injury/Trauma Algorithm (mdcalc.com)

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The biggest challenge in managing a child with a mild to moderate head injury is deciding whether to organise a CT scan or not. Balancing the risk of ionising radiation (and with it the small, but definite, risk of a future brain tumour or leukaemia) against the risk of missing a significant brain injury is mitigated to some extent by using a clinical decision rule, like the PECARN, CATCH or CHALICE rules. These rules are extremely sensitive with very few false negatives and excellent negative prediction values, meaning if you follow them, you're unlikely to miss a clinically important brain injury (cTBI). Their problem is their specificity is low with plenty of false positives, meaning most of the children who have a scan won't actually have a brain injury. (If you'd like a refresher on sensitivity, specificity, NPV and PPV in head injury decision rules, check out Damian's critical appraisal talks in DFTB Essentials.)

Over the last 6 years, Australasia's PREDICT network has been a publishing powerhouse on paediatric head injuries from their Australasian Paediatric Head Injury Research Study (APHIRST for short). In their cohort of 20,000 children the team have been able to tell us that of PECARN, CATCH and CHALICE, the PECARN rule has the highest sensitivity. They've also shown that planned observation leads to significantly lower CT rates, with no difference in missed cTBI. And probably most telling of all, they've told us that, without using any rules, their clinicians are already very good at identifying children with a cTBI with a sensitivity almost as high as PECARN's, but with a very low baseline CT rate.

Nonetheless, clinical decision rules do play their role. And so, when they asked their network what an ideal decision rule would tell them, their clinicians highlighted the gaps in the existing guidelines: What should we do with a child with a delayed presentation up to 72 hours after the head injury? What about a child with a bleeding disorder and a head injury? What about a child with a VP shunt and a head injury? Or an intoxicated child with a head injury? The list goes on.

And so, in true PREDICT style, they decided to develop their own guideline.

This week marks a landmark day for paediatric head injury management worldwide as PREDICT launch their guideline for mild to moderate head injuries in children. The risk criteria from the PECARN rule, the best performing prediction rule in the APHIRST study, play a central role, supported by an extensive literature search, including studies from PECARN and PREDICT on the risk associated with VP shunts and bleeding risks. PREDICT have pulled all the data into one comprehensive, evidence-based guideline for managing, what has previously been considered, some of the less clear-cut paediatric head injury presentations. Let's explore the algorithm and run through a series of cases.
Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children - Algorithm (2021). PREDICT, Melbourne, Australia.
How was the guideline derived?

Building on the existing high-quality clinical decision rules, the PREDICT group conducted a systematic review of the literature to include more recently published evidence. To develop the new PREDICT guideline, they used a GRADE-ADOLOPMENT approach, adopting, adapting or developing new recommendations, which are labelled in the main guideline as 'evidence-informed recommendations', 'consensus-based recommendations' or 'practice points'.

What does it say?

This guideline is here to tell us what to do with children with a mild or moderate head injury, with a GCS of 14 or 15, or a child with a GCS ≤ 13 with a normal CT scan. The 'who to discharge, who to observe and who to scan' part of the guideline is succinctly summarised with a two-page algorithm. Page 1 has an easy to follow flowchart, supplemented by footnotes and Appendix with modified guidance for special conditions on page 2.

The bottom line

What I like so much about this guideline is that it answers so many of our " what about the child with a head injury plus...? " questions. With the evidence-based recognition that senior clinicians who choose to observe rather than scan a child reduce the CT rate without increasing the number of missed cTBIs, this guideline also allows senior clinicians to make a risk assessment on a case by case basis, while remaining fluid enough to upgrade or downgrade a child's risk if their clinical picture changes. Although designed for use in Australia and New Zealand, I can see it being immensely useful outside Australasia and am looking forward to putting its pearls of wisdom to use.

Case 1

Case 2

Case 3

Case 4

Case 5

Cases 6 and 7

Case 8

Cases 9 and 10

Case 11

Case 12

Case 13

Case 14

Case 15

References

Babl FE, Tavender E, Dalziel S. On behalf of the Guideline Working Group for the Paediatric Research in Emergency Departments International Collaborative (PREDICT). Australian and New Zealand Guideline for Mild to Moderate Head injuries in Children - Algorithm (2020). PREDICT, Melbourne, Australia.

Babl FE et al. Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study. 2017. 389;10087:2393-2402. DOI: https://doi.org/10.1016/S0140-6736(17)30555-X

Babl FE et al. A prospective observational study to assess the diagnostic accuracy of clinical decision rules for children presenting to emergency departments after head injuries (protocol): the Australasian Paediatric Head Injury Rules Study (APHIRST). BMC Pediatr. 2014. 13;14:148. DOI: 10.1186/1471-2431-14-148

Singh S et al. The Effect of Patient Observation on Cranial Computed Tomography Rates in Children With Minor Head Trauma. Acad Emerg Med. 2020. 27:832-843. DOI: 10.1111/acem.13942

Borland M et al. Delayed Presentations to Emergency Departments of Children With Head Injury: A PREDICT Study. Ann Emerg Med. 2019. 74:1-10. DOI: 10.1016/j.annemergmed.2018.11.035

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Predicting paediatric traumatic brain injuries

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The biggest challenge in managing a child with a mild to moderate head injury is deciding whether to organise a CT scan or not. Balancing the risk of ionising radiation (and with it the small, but definite, risk of a future brain tumour or leukaemia) against the risk of missing a significant brain injury is mitigated to some extent by using a clinical decision rule, like the PECARN, CATCH or CHALICE rules.

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Have a look at the Royal College of Radiology paediatric trauma protocols for imaging in chest and abdo. NB this was published in 2014 so is 10 years old. Paediatric trauma protocols | The Royal College of Radiologists (rcr.ac.uk)

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A PEM Adventure
Ranulf is a 14-year-old explorer.

He has already climbed Ben Nevis in Scotland, visited the Gobi desert (possibly from the comfort of his parents 4 x 4, but who's judging) and has his bronze D of E nailed.

Whilst you were busy managing head injuries and drownings, Ranulf had been out with a group of boys from school this evening. They had been enjoying a celebratory dinner following their safe return from a trip to the Amazon rainforest. Spirits were running high amongst the young teenagers as they ate and drank, regaling their parents with tales from the trip.

Ranulf's best friend, Tarquin, had particularly enjoyed their lesson in arctic spear-fishing and, in an attempt to demonstrate the native technique, grabbed a knife wedged into a nearby piece of stilton. Tarquin lifted the knife high above the remains of his fish course. But unfortunately for Ranulf, as Tarquin stood, he slipped on a blob of spilt quince jelly. Lurching awkwardly sideways, Tarquin fell towards his best friend, the knife lunging deep into the left side of his chest.

Ranulf went white with the shock.

Tarquin screamed and pulled the knife straight back out, but blood started to spurt from the decent-sized incision he had accidentally made.

Grabbing a pristine white table napkin to apply pressure to the wound, Ranulf's class teacher and expedition leader called the ambulance as chaos descended on the restaurant.
All you know, back in ED, is that the ETA is 10 minutes, and there is a single stab wound to the chest.

The trauma call goes out.

You will be running the show today, and you want to use your preparation time well. So, what are your key priorities? A stab wound means there could be:

- Significant bleeding - you consider putting out a Major Haemorrhage call
- Significant chest injuries - you ask your general surgeon to get the chest drain kit prepared
- Significant intra-abdominal injuries - you are not sure until you see the patient exactly where the problem will be
- Significant pain - they are coming in un-intubated with a paramedic crew. You ask your anaesthetist to get ready to sedate or intubate depending on their status
- Significant risk to the department - you make sure security is aware
And your patient arrives.

Ranulf is quite a sweet, round-faced boy, accompanied by his traumatised-looking mother as he is wheeled to your trauma bay.

Smiling reassuringly at Ranulf and his mum, you turn around to take the ambulance handover, which is beautifully presented ATMIST style:

A - We have a 14-year-old male by the name of Ranulf
T - Ranulf was accidentally stabbed with a cheese knife at 735pm
M - HIs friend slipped while holding the knife, and it entered the left chest, just adjacent to the nipple. The knife was immediately removed, and significant blood loss was visible when we arrived on scene.
I - We suspect a left-sided haemothorax or haemopneumothorax, but there are no other injuries
S - HR has been 100-120, BP 110/78, borderline saturations 93% in air, but 98% % in 100% O2 via non-rebreathe. RR 25-30. Temperature 36.8C. GCS 15.
T - He's got a single grey cannula in situ, and we've given him a 5 mg bolus of IiV morphine on the way in
The primary survey

Thanking the paramedic team, you ask the T&O SHO to proceed with a primary survey. She calls out her findings:

A - OK
B - 1 puncture mark to the anterior left chest wall, covered with a three-sided dressing. Actively oozing. There is decreased air entry, dull percussion at the left base, and minimal chest wall movement. RR 30 Sats 96% in 100% O2 via NRB
C - Tachycardic, feeling cold and clammy HR 124 BP 116/80, soft abdomen, no other signs of blood loss
D - eyes open, can obey commands, not talking much but can answer questions, GCS 15
E - T 36.8C

Right now, though, Ranulf's' Mum looks whiter than he does.

"Is he going to be OK?

You hate questions like this at the start of a trauma case

"He's in the best place," you tell her.

And it's true. In 2021, Evans and colleagues (1) compared adolescent mortality rates in adult, children's and mixed major trauma centres across the UK. 21 033 cases were included in the logistic regression analysis. They showed that even when controlling for injury severity, mechanism of injury and physiological parameters, crude 30-day trauma-related mortality was lowest for adolescents attending a dedicated children's MTC at 2.5%, followed by a mixed centre at 4.4% and highest at 4.9% for adolescents up to the age of 25 attending an adult only MTC.
"I will sit down and have a proper chat with you shortly once we've stabilised him."

Your priority is to decompress the chest and replace lost blood. So you ask that:

- A major haemorrhage call is put out
- 2 x wide bore IV access is obtained, blood is taken, and a dose of tranexamic acid is given.

Ranulf seems to be maintaining his airway - so what do you do next?

You turn to your anaesthetist, "We could put this drain in under ketamine sedation or, do you think it would be better to go ahead and intubate him now?

"I'm easy," says your colleague,

"There's probably no right or wrong answer," he continues."The priority is the drain and blood replacement. You could argue that sedation is safer as you won't be manipulating the airway in a haemodynamically unstable patient. However, once intubated, you can do whatever interventions are needed for Ranulf and have full airway control".

The ODP is caught up leaving theatres and has not yet made it down to ED. So, in the interests of time, you opt for ketamine now, intending to intubate later if required.
Would you like a pigtail catheter or a surgical chest tube?

In 2021, Kulvatunyou, Bauman and colleagues compared the insertion of traditional 28-32Fr chest tubes with 14Fr pigtail catheters for drainage of traumatic haemothorax. They looked at 119 adult patients from an (unspecified) number of trauma centres.

The primary outcome measure was chest drain failure, i.e., retained haemothorax requiring a secondary interventional procedure. They found NO difference in drain failure rates ( 11% pigtail vs 13% chest tube P=0.74), total daily volume drained or length of ICU stay between groups.

However, patients in the pigtail catheter group rated their experience and tolerability of the insertion procedure much better than the chest tube group. The major caveat was that they excluded patients 'requiring emergent placement' of the drain. This was determined by the treating physician, making it difficult to know whether or not we could extrapolate the findings to Ranulf.
With that in mind, you request a 30 FR chest tube and make a mental note to review the evidence in more detail, especially around irrigation, as it would make a great departmental QUIP.

You ask the paediatric SHO to write up a dose of antibiotics to reduce the risk of empyema formation and turn back around to see that the surgical reg appears to be drawing on the patient's arm.

He notices your quizzical look and explains that he uses the mid-arm point technique to site the drain.

"We do it all the time in grown ups", he says, "to identify a safe zone for pleural decompression. It's much quicker and easier than counting rib spaces. He's a big enough kid, I am sure it will work for him".
Hmmmm... it's a LEFT-sided wound, and you want to ensure you will be inside the triangle of safety.

Where and how should we decompress the chest?

Enter Nuala Quinn's team and their recent paper on using the Mid-Arm Point in Paediatrics.

They looked at 392 children across four sites who required chest X-rays. Before the x-ray, they marked the mid-arm point and used radiopaque markers at the corresponding chest level to identify where a drain could be inserted.

When they reviewed the x-rays, 83% of markers were within the 'safe zone' for pleural decompression (4th to 6th intercostal spaces). When outside the 'safe zone', markers were nearly always too caudal. By transposing the mid-arm point one intercostal space cranially in those ≥ four years, performance improved significantly. 91% of markers were in the 'safe zone'. This was an X-ray-based study, and the rule hasn't been tested in vivo, but the results look promising. What's more, Nuala and her team have coined the handy Rule of Fours to help you make sure your drain insertion goes smoothly:

Rule 1: Four steps in a 'good plan'

Rule 2: Fourth (or fifth) intercostal space as the basis for siting a 'good hole'

Rule 3: 4× uncuffed endotracheal tube size (4× [age/4 + 4]) to guide the selection of a 'good tube'

Rule 4: 4 cm mark for a 'good stop' to ensure the drain is in far enough but not too far.
Happily, the drain goes in smoothly. And blood comes out. Quite quickly. Time to get a transfusion started.

But what are you going to give...
Do you want to transfuse with?

There is evidence for using balanced ratios in children, but this comes from retrospective case note reviews.

A recent review was conducted on Trauma Quality Improvement Program data between 2014 and 2016. This generated a sample of 1233 paediatric trauma patients who had received at least 1 unit PRBC and FFP. They stratified patients according to the ratio of FFP: PRBC received (1:1, 1:2, 1:3 and 1:3+) and performed logistic regression analyses for various outcomes.

Blood product ratios made no difference to complications such as ARDS and AKI. However, patients in the 1:1 group had the lowest 24-hour mortality ( 14% vs 18% vs 22% vs 24%; p = 0.01), and in-hospital mortality ( 32% vs 36% vs 40% vs 44%; p = 0.01). In addition, the 1:1 group had the lowest overall PRBC transfusion requirements (p < 0.01).

So, while we await a prospective trial in children, the evidence looks to be stacked in favour of keeping the blood product ratios balanced.

But what about fibrinogen replacement?

Fibrinogen is crucial in achieving hemostasis, and most major haemorrhage protocols widely advise early replacement. CRYOSTAT-1 showed us that early fibrinogen replacement with cryoprecipitate almost halved mortality from traumatic haemorrhage.

However, CRYOSTAT-2 suggests that empirical use of up-front cryoprecipitate may cause harm. In this phase III multicentre randomised controlled trial of nearly 1500 adult trauma patients, there was no benefit to 28-day all-cause mortality amongst patients receiving upfront cryoprecipitate, and a trend towards increased mortality if given within the first hour. ( 34% 28-day mortality if given under 45 mins; 29% in the first hour vs 26% standard care, non-significant).

This tells us (as if we didn't already know) that clotting in trauma is complex, and one size does not necessarily fit all when it comes to replacing blood products.

Trauma-induced coagulopathy (TIC) is characterised by widespread microvascular haemorrhage. Traditionally thought to result from the dilutional effects of massive transfusion, acidaemia or hypothermia, trauma-induced coagulopathy is now known to be triggered at the time of injury, long before these factors have developed or any medical intervention has taken place.

The mechanisms behind TIC are complex and interrelated, but all stem from the impact of endothelial activation on the clotting system. ROTEM - or thromboelastography - allows us to examine a patient's coagulation profile in real-time and target transfusion products based on specific deficits. This is helpful for a TIC patient whose needs may not match the products or ratios written into our trauma protocols. The next few years are likely to see us move away from blind, empirical prescribing to a targeted transfusion pathway that can potentially improve outcomes in paediatric trauma.
Back in ED with Ranulf, and pack two has gone through.

But when you reassess your patient, things are getting worse. His heart rate is creeping up, now 140. You do a gas to check the base excess and calcium and move on to pack three...

Five minutes later, however, the BP reading starts to alarm, now reading at 90/67.

What are you going to do?

You know you need to "turn off the tap", but this is a non-compressible torso haemorrhage; you need to open the chest.

"What about REBOA?" asks that brainy surgical registrar.

Really, in a 14-year-old? You are not sure.
How should we deal with Ranulf's bleeding?
The trauma surgeon arrives, and you agree to proceed to the theatres. Ranulf has an RSI intubation and is transferred upstairs with ongoing volume resuscitation.

Multiple bleeding intercostal vessels are tied off at thoracotomy, and the pleural cavity is washed out. Ranulf spends the next few days in PICU and a week in the children's ward but fully recovers.

After extensive exposure to the fabulous trauma team, he makes a substantial donation to the local air ambulance, invests and develops a 'cheese safety knife' and becomes a world leader in the Swiss cheese model of human factors.

Brie-liiant! This post is part of the PEM Adventure at NEPTUNE 2023, hosted by Dani, Kat, Costas and Sarah. NEPTUNE 2023 was inaugural UK PEM trauma conference, hosted by Nottingham University Hospitals Trust, one of the largest major trauma centres in the UK.
References

Akl M, Anand T, Reina R, El-Qawaqzeh K, Ditillo M, Hosseinpour H, Nelson A, Obaid O, Friese R, Joseph B. Balanced hemostatic resuscitation for bleeding pediatric trauma patients: A nationwide quantitative analysis of outcomes. J Pediatr Surg. 2022 Dec;57(12):986-993.

Baraniuk S, Tilley BC, del Junco DJ, Fox EE, van Belle G, Wade CE, Podbielski JM, Beeler AM, Hess JR, Bulger EM, Schreiber MA, Inaba K, Fabian TC, Kerby JD, Cohen MJ, Miller CN, Rizoli S, Scalea TM, O'Keeffe T, Brasel KJ, Cotton BA, Muskat P, Holcomb JB; PROPPR Study Group. Pragmatic Randomized Optimal Platelet and Plasma Ratios (PROPPR) Trial: design, rationale and implementation. Injury. 2014 Sep;45(9):1287-95.

Brenner M, Bulger EM, Perina DG, Henry S, Kang CS, Rotondo MF, Chang MC, Weireter LJ, Coburn M, Winchell RJ, Stewart RM. Joint statement from the American College of Surgeons Committee on Trauma (ACS COT) and the American College of Emergency Physicians (ACEP) regarding the clinical use of Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA). Trauma Surg Acute Care Open. 2018 Jan

Curry N, Rourke C, Davenport R, Beer S, Pankhurst L, Deary A, Thomas H, Llewelyn C, Green L, Doughty H, Nordmann G, Brohi K, Stanworth S. Early cryoprecipitate for major haemorrhage in trauma: a randomised controlled feasibility trial. Br J Anaesth. 2015 Jul;115(1):76-83. doi: 10.1093/bja/aev134. Epub 2015 May 19. PMID: 25991760.

Evans J, Murch H, Begley R, Roland D, Lyttle MD, Bouamra O, Mullen S. Mortality in adolescent trauma: a comparison of children's, mixed and adult major trauma centres. Emerg Med J. 2021 Jul;38(7):488-494.

Jansen, J.O., Cochran, C., Boyers, D. et al. The effectiveness and cost-effectiveness of resuscitative endovascular balloon occlusion of the aorta (REBOA) for trauma patients with uncontrolled torso haemorrhage: study protocol for a randomised clinical trial (the UK-REBOA trial). Trials 23, 384 (2022).

Kugler NW, Carver TW, Milia D, Paul JS. Thoracic irrigation prevents retained hemothorax: A prospective propensity scored analysis. J Trauma Acute Care Surg. 2017 Dec;83(6):1136-1141.

Kulvatunyou N, Bauman ZM, Zein Edine SB, de Moya M, Krause C, Mukherjee K, Gries L, Tang AL, Joseph B, Rhee P. The small (14 Fr) percutaneous catheter (P-CAT) versus large (28-32 Fr) open chest tube for traumatic hemothorax: A multicenter randomized clinical trial. J Trauma Acute Care Surg. 2021 Nov 1;91(5):809-813.

Laan DV, Vu TD, Thiels CA et al. Chest wall thickness and decompression failure: a systematic review and meta-analysis comparing anatomic locations in needle thoracostomy. Injury 2016; 47: 797- 804.

Phillips R, Moore H, Bensard D, Shahi N, Shirek G, Reppucci ML, Meier M, Recicar J, Acker S, Kim J, Moulton S. It is time for TEG in pediatric trauma: unveiling meaningful alterations in children who undergo massive transfusion. Pediatr Surg Int. 2021 Nov;37(11):1613-1620.

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.

Teague WJ, Amarakone KV, Quinn N. Rule of 4's: Safe and effective pleural decompression and chest drain insertion in severely injured children. Emerg Med Australas. 2019 Aug;31(4):683-687.
https://www.nhsbt.nhs.uk/clinical-trials-unit/current-trials-and-studies/cryostat-2/

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Sarah and Kat ask the NEPTUNE audience just how they would manage a nasty penetrating chest injury.

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Do examination and diagnostics match up?

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Do examination and diagnostics match up?

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Paediatric mental health (MH) admissions to emergency departments and hospitals are increasing worldwide, including in the UK, USA and Australia. COVID-19 has changed this somewhat, at least in the UK, with a decrease in presentations in the first national lockdown. As the UK and the rest of the world return to the "new normal" in 2021, it is likely that paediatric MH presentations could rise back to pre-covid levels.

These presentations can be challenging to manage in the emergency department. A variety of tools have been developed to help with history taking and disposition, including the HEEADSSS, HEADS-ED, Risk of Suicide Questionnaire (RSQ) and many others. Here we take look at a recent paper looking at the utility of one of these scoring systems, the HEADS-ED.

Cappelli M, Zemek R, Polihronis C, Thibedeau NR, Kennedy A, Gray C, Jabbour M, Reid S, Cloutier P. The HEADS-ED: Evaluating the Clinical Use of a Brief, Action-Oriented, Pediatric Mental Health Screening Tool. Pediatr Emerg Care. 2020 Jan;36(1):9-15. doi: 10.1097/PEC.0000000000001180. PMID: 28538605

What is HEADS-ED?

The HEADS- ED was developed in 2012 as a tool specifically to obtain a psychosocial history from adolescents in the ED, when it was found found to predict psychiatric consult and admission to inpatient psychiatry with a sensitivity of 82% and a specificity of 87% (area under the receiver operator characteristic curve of 0.82, P < .01). This was a promising finding.

What was the aim of the paper?

There was a composite primary aim:

1. To examine the utility and decision validity of the HEADS-ED tool for Paediatric Emergency Department (PED) physicians in guiding consultations to psychiatry and crisis services for patients presenting with mental health concerns.

2. To examine the concordance between PED physicians and crisis intervention workers (CIWs) in communicating the level of need and action required amongst a sub-sample for the patients.

Where was the paper set?

This study was conducted in the PED at the Children's Hospital of Eastern Ontario, Ottawa, a tertiary hospital with 70,000 annual visits a year. 3100 ( 4.5%) of these are related to mental health concerns. Approximately two-thirds of the MH patients are seen by the PED physicians who either discharge to the community or request a consultation with specialised MH services. Those who don't need any medical care (other 1/3 rd ) are referred directly to the CIWs.

What did they do?

The HEADS-ED was added to the charts of every child aged 12 to 17 presenting to the ED with a MH concern, completed by the PED physicians.

Only adolescents who had a complete HEADS-ED were included in the study. If they were younger than 12 or older than 17, or if their presentation was not with a MH concern, then they were excluded from the study.

What did they find?

There were 2704 mental health presentations during the study period. After various exclusions for wrong age or incomplete or no HEADS-ED assessment, 639 adolescents were included in the study. Of those 140 (22%) were seen by the CIWs.

How good is HEADS-ED at predicting consultation or admission?

The study team looked at how well the screening tool corresponded to consultation for full psychiatric assessment and subsequent admission to inpatient care. 254 (39.7%) children and young people required a consultation by the CIW or psychiatrist. 96 (15.3%) were admitted.

Chi-squared was applied to each of the seven HEADS-ED items to examine whether the scores correlated to request for consultation and subsequent admission.

Inpatient admission was highly associated with higher scores in education, activities and suicidality

Consultations with CIW or psychiatry was associated with higher mean HEADS-ED score (mean 6.91)

Those who did not need a consultation had a mean score 4.70 (n=254)

Those who were discharged had a lower mean score than those admitted (5.28 vs 7.21).

As the HEADS-ED score increased, the likelihood of admission did also.

How reliable is the score at predicting admission?

A HEADS-ED score of 8 or more and a suicidality score of 2 led to 164% more requests for consults from the PED team (relative risk, 2.64; confidence interval, 2.28-3.06)

140 patients had the HEADS-ED completed by both PED physicians and CIWs. The PED physicians rated patients higher on all HEADS-ED items and composite scores compared with CIW; however, not all were statistically significant.

Agreement on ratings ranged from 61.7% to 92.9% with the highest agreement being suicidality and lowest agreement being activities and peers.

Bottom line - Should I change my clinical practice after reading this paper?

Maybe.

The HEADS-ED can be useful in helping take a psychosocial history in adolescents in the PED.

This may help confer concern when referring to the MH team. It cannot currently be used as a risk assessment as this was a single centre site, in Canada. More work is needed to understand its external validity.

Final words from Andy Tagg

Patients with mental health concerns are increasing in numbers. Rather than skip over them for something easy it is important that we all get comfortable with asking uncomfortable questions. One of the challenges of formal tools is that they rend to direct the conversation and turn it into a tickbox exercise rather than a free-flowinng conversation. Clinicians need to be able to jump from topic to topic as they develop rapport with the child or young person in front of them.

With four times as many exclusions as inclusions I wonder how well the clinicians did if they did not use the tool. My first instinct would be that clinical gestalt, in experienced clinicians, would be as useful, if not better than the HEADS-ED tool. Where I see the potential value is for those healthcare workers with less experience, that might need a little guidance along the way.

References

1. Lo CB, Bridge JA, Bridge JA, et al. Children's mental health emergency department visits: 2007-2016. Pediatrics [Internet] 2020;145(6). Available from: https://doi.org/10.1542/peds.2019-1536

2. Irteja Islam M, Khanam R, Kabir E. The use of mental health services by Australian adolescents with mental disorders and suicidality: Findings from a nationwide cross-sectional survey. PLoS One [Internet] 2020 [cited 2021 Jan 3];15(4). Available from: https://doi.org/10.1371/journal.pone.0231180

3. Lawrence D, Johnson S, Hafekost J, et al. The mental health of children and adolescents: Report on the second Australian child and adolescent survey of mental health and wellbeing [Internet]. Austrialian Government; 2015 [cited 2021 Jan 3]. Available from: https://www1.health.gov.au/internet/main/publishing.nsf/content/9DA8CA21306FE6EDCA257E2700016945/$File/child2.pdf

4. Tolentino A, Symington L, Jordan F, Kinnear F, Jarvis M. Mental health presentations to a paediatric emergency department. Emerg Med Australas [Internet] 2020 [cited 2021 Jan 3];1742-6723.13669. Available from: https://onlinelibrary.wiley.com/doi/10.1111/1742-6723.13669

5. Williamson A, Skinner A, Falster K, Clapham K, Eades SJ, Banks E. Mental health-related emergency department presentations and hospital admissions in a cohort of urban Aboriginal children and adolescents in New South Wales, Australia: findings from SEARCH. BMJ Open [Internet] 2018 [cited 2021 Jan 3];8:23544. Available from: http://bmjopen.bmj.com/

6. UKParliment. Written questions and answers - Written questions, answers and statements - UK Parliament [Internet]. UIN 181292. 2018 [cited 2021 Jan 3];Available from: https://questions-statements.parliament.uk/written-questions/detail/2018-10-18/181292

7. Ougrin D. Debate: Emergency mental health presentations of young people during the COVID-19 lockdown. Child Adolesc Ment Health [Internet] 2020;25(3):171-2. Available from: https://doi.org/10.1111/camh.12411

8. Cappelli M, Gray C, Zemek R, et al. The HEADS-ED: a rapid mental health screening tool for pediatric patients in the emergency department. Pediatrics 2012;130(2):e321-7.
Other useful resources
Andrew Tagg. Mental Health Screening, Don't Forget the Bubbles, 2019. Available at:
https://doi.org/10.31440/DFTB.21114
Henry Goldstein. Adolescent Inpatient Psychiatry, Don't Forget the Bubbles, 2017. Available at: https://doi.org/10.31440/DFTB.11391

Ester Sabel. The ABC of Self-Harm in Young People - A Psychiatric Approach to Resuscitation. 2019. https://www.rcemlearning.co.uk/foamed/the-abc-of-self-harm-in-young-people-a-psychiatric-approach-to-resuscitation/

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Get comfortable asking the uncomfortable questions

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This post accompanies the talk I gave at the adolescent health session of the Australasian College for Emergency Medicine Annual Scientific Meeting in Hobart. According to the World Health Organisation, mental health disorders account for 16% of the global disease burden for illness and injury in those aged between 10 and 19 years of age.

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Elizabeth Harte, Ana Waddington, Marie-Claire O’Brien

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Trauma is not just about what happens to the body but also what happens to the mind. How can we provide better trauma-informed care?

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Not everyone has a peachy childhood - what impact do adverse childhood events have on our patients?

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Secondary analysis from the Kuppermann paper looking at serum sodium v mental status

Blog review here: https://dontforgetthebubbles.com/sodium-and-cerebral-oedema/

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Nicole S. Glaser, Michael J. Stoner, Aris Garro, Scott Baird, Sage R. Myers, Arleta Rewers, Kathleen M. Brown, Jennifer L. Trainor, Kimberly S. Quayle, Julie K. McManemy, Andrew D. DePiero, Lise E. Nigrovic, Leah Tzimenatos, Jeff E. Schunk, Cody S. Olsen, T. Charles Casper, Simona Ghetti, Nathan Kuppermann; for the Pediatric Emergency Care Applied Research Network (PECARN) DKA FLUID Study Group, Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis. Pediatrics September 2021; 148 (3): e2021050243. 10.1542/peds.2021-050243

Download citation file:

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Serum Sodium Concentration and Mental Status in Children With Diabetic Ketoacidosis

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10.1542/6250549650001Video AbstractPEDS-VA_2021-0502436250549650001OBJECTIVES. Diabetic ketoacidosis (DKA) is typically characterized by low or low-normal serum sodium concentrations, which rise as hyperglycemia resolves. In retrospective studies, researchers found associations between declines in sodium concentrations during DKA and cerebral injury. We prospectively investigated determinants of sodium concentration changes and associations with mental status alterations during DKA.METHODS.

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Secondary analysis of the Kuppermann paper looking at AKI

43% of the original cohort had AKI, more so in older children and those with lower pHs, higher HR, higher glucose, higher corrected sodiums and higher ureas. Children with AKI had lower scores in short term memory tests (not sig) and lower IQ 3-6 months later (100 v 103, p=0.005)

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Frequency and Risk Factors of Acute Kidney Injury During Diabetic Ketoacidosis in Children and Association With Neurocognitive Outcomes - PubMed

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These findings suggest that AKI may occur more frequently in children with greater acidosis and circulatory volume depletion during DKA and may be part of a pattern of multiple organ injury involving the kidneys and brain.

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And https://rebelem.com/pediatric-dka-do-fluids-really-matter/

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Sweet and Salty - fluids in DKA - Don’t Forget the Bubbles

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During our training in paediatric emergency medicine most of us will have been cautioned repeatedly of the dangers of over-zealous fluid administration in children with diabetic ketoacidosis. Cerebral oedema is the feared complication of this disease process and, as traditional wisdom would have it,…

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Pediatric DKA: Don't Fear the Fluids!
March 15, 2020
In this episode, EMRA*Caster Dr. Jessie Werner speaks with Professor and Chair of Emergency Medicine at UC Davis, Dr. Nathan Kuppermann, about ground-breaking research in Pediatric DKA. Learn the dos and don'ts of management and learn to embrace those fluids!

Overview

Why do we fear fluids in pediatric DKA patients? Do they really cause cerebral edema or is that just what you've been taught for years? Did you know that with each episode of DKA children lose some memory?

In this episode of EMRA*CAST, Dr. Jessie Werner speaks with Dr. Nathan Kuppermann about ground-breaking research in Pediatric DKA. Learn the dos and don'ts of DKA management in children and understand why you should embrace the fluids!

Key Points

DKA: pH<7.25 or bicarb <15 with ketones in the urine

Pediatric DKA patients who develop cerebral edema don't do so because of fluids, but because they are SICKER

Several risk factors have been identified for developing cerebral edema:

higher BUN (greater dehydration)

lower bicarb (worsening acidosis)

bicarbonate administration

serum sodium not rising as expected as glucose went down

The brain in DKA is dehydrated and inflammatory markers are elevated. Brain reperfusion can result in vasogenic edema (similar to what is seen in stroke patients)

When rehydrating DKA patients:
replace this 4L over 48 hours in addition to maintenance fluids (4:2:1 rule)

Calculate the fluid deficit (assume 7-10% and base this on body weight)

example: 40-kg child who is 10% dehydrated is 4L down

if you suspect cerebral edema, do not wait to initiate treatment

References

Kuppermann N, Ghetti S, Schunk JE, et al. Clinical trial of fluid infusion rates for pediatric diabetic ketoacidosis. 2018;378:2275-2287.

Glaser NS, Ghetti S, Casper TC, Dean JM, Kuppermann N, Pediatric Emergency Care Applied Research Network (PECARN) DKA FLUID Study Group. Pediatric diabetic ketoacidosis, fluid therapy, and cerebral injury: the design of a factorial randomized controlled trial. Pediatr Diabetes . 2013;14(6):435-446.

Glaser NS, Wootten-Gorges SL, Marcin JP, et al. Mechanism of cerebral edema in children with diabetic ketoacidosis. 2004;145:164-171.

Glaser N, Barnett P, McCaslin I, et al. Risk factors for cerebral edema in children with diabetic ketoacidosis. N Engl J Med. 2001;344(4):264-269.

Pediatric Emergency Care Applied Research Network (PECARN) http://www.pecarn.org/

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In this episode, EMRA*Caster Dr. Jessie Werner speaks with Professor and Chair of Emergency Medicine at UC Davis, Dr. Nathan Kuppermann, about ground-breaking research in Pediatric DKA. Learn the dos and don'ts of management and learn to embrace those fluids!

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In this week's tutorial we critically appraised the landmark Kuppermann et al RCT: Clinical Trial of Fluid Infusion Rates for Pediatric Diabetic Ketoacidosis