The Mornington Meet-Up

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).

Further reading

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 – coming soon

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.

Further Reading

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.

Further reading

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.

Further reading

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).

Further reading

Ring-Xiety and how to unplug by Henry Goldstein on DFTB

Save the Date – DFTB18

We couldn’t just stop after one conference, could we? Next year we will be swapping the glamour of Brisvegas for the coffee capital of Australia, Melbourne. With a day dedicated to some fantastic pre-conference workshops, it’s going to be an event not to be missed so save the date.

 

 

Bookmark www.dftb18.com and keep on checking back for more details.

Tickets will go on sale on the 1st of November at 0900 AEST.

 

If you want to speak at DFTB18 then you have a couple of weeks to get your pitch into us – don’t miss out!

Trust me, I’m a GP

Here at DFTB we are keen to promote a culture that breaks down the silos of who can do what. We all care about one thing, above all else, the wellbeing of the children we treat. Working in a hospital environment sometimes gives us a skewed view of illness. Just like every neurosurgeon that sees a patient with a headache is concerned about a sub-arachnoid haemorrhage, every doctor in the paediatric emergency department is concerned about missing sepsis.

With winter (in the south) dragging on, we are seeing more and more children in the emergency department. It has become so bad that some hospitals are even sending out tweets suggesting patients get taken elsewhere. Why not their general practitioner?

Today I’m going to take a look at the following paper and its controversial conclusions.

Freed GL, Spike N, O’Hara J, Hiscock H, Rhodes AL. National study of parental confidence in general practitioners. Journal of Paediatrics and Child Health. 2017 Sep 3.

 

How was it performed?

A representative sample of 2100 Australians  completed an online survey. They had to act as caregivers for a child under the age of 17, live in Australia and have internet access. This sample group was taken from a larger research panel of over 120,000 Australians and was distributed across the states in proportion to the population. The survey was anonymous and incentivized to improve completion rates.

 

What were the results?

Whilst there are days when I think every child in the neighbourhood has been brought to our ED the survey results suggest that a whopping 93% of caregivers take their child to the GP.

Putting that in perspective it means that if, in a 10 hour shift, I see 8 children with a cough, cold or runny nose that I think could have gone to to their GP another 194 are being cared for by general practitioners.

But were the parents happy with the advice they received? 

When it comes to minor illness 89% (1884 of 2100) respondents were either mostly or completely confident in the health care provider. A similar number (89%) were also confident that their GP could handle a minor injury or two.

So what did the authors conclude?

The authors concluded that fewer than 44% of parents expressed complete confidence in their GP in dealing with general health issues for their child. A regression analysis revealed that lower levels of confidence were associated with younger parents and a higher level of attained education whereas increased confidence was associated with older parents and visiting a regular GP.

What has the media said?

A clickbait ad-driven press reads the abstract and misses the raw data. Table 2 (reprinted above) clearly states that only 4% of parents bypass their GP’s and go straight to the ED.

What do I think?

Whilst I think the paper asks some interesting questions I would reframe the conclusion around the fact that 89% of parents are mostly confident that their GP knows what they are doing. Freed et al. argue the semantics of the term complete confidence suggesting that parents who are not completely confident might be more inclined to present to the emergency department I would like to know the baseline level of complete confidence in all doctors.  

There has been an increase in the number of children presenting to the ED and it is important to drill down and find out why, especially when so-called low acuity cases are on the rise. An earlier survey, carried out by Freed, of four metropolitan hospitals in Victoria (one of which was a tertiary paediatric centre) showed that only 43% of parents had attempted to make an appointment with a GP prior to attendance. When asked why they went to hospital it seemed that the majority (94%) of the parents felt that their child had a serious condition. There is clearly a disconnect between what a parent thinks is serious (and thus warrants hospital attention) and what a triage nurse or treating doctor thinks is not serious (and thus should have gone to the GP).

Borland et al. also point out some possible inconsistencies with the use of triage category as a surrogate marker for acuity. A child with persistent bruising and lethargy may be given a triage category of 4 or 5 marking them as low acuity but their underlying diagnosis of leukaemia would never be classified as low acuity. Triage categories provide arbitrary time based targets in which patients should be seen and may not reflect the underlying seriousness of their condition. If you look at the Australian Institute of Health and Welfare (AIHW) definition of a low acuity GP-type patient you can see the problem…

….as one who did not arrive by ambulance/police/correctional vehicle, was not admitted, had a triage category 4 or 5, was not referred to another hospital and did not die.

What none of the papers provide is outcome data. I would be interested to know what exactly the themes across the low-acuity presentations were and what were the outcomes of those visits in terms of processes that cannot be readily performed in a busy general practice (blood tests, radiographs, ultrasounds) and admissions.

Other studies of child attendances also highlight that one of the major drivers for attendance is not lack of confidence but parental perceived seriousness. How one changes a culture is then up for debate.

References

Freed GL, Spike N, O’Hara J, Hiscock H, Rhodes AL. National study of parental confidence in general practitioners. Journal of Paediatrics and Child Health. 2017 Sep 3.

Freed GL, Allen AR, Turbitt E, Nicolas C, Oakley E. Parent perspectives and reasons for lower urgency paediatric presentations to emergency departments. Emergency Medicine Australasia. 2016 Apr 1;28(2):211-5.

Turbitt E, Freed GL. Paediatric emergency department referrals from primary care. Australian Health Review. 2016 Dec 21;40(6):691-5.

Borland M, Skarin D, Nagree Y. Comparison of methods used to quantify general practice‐type patients in the emergency department: A tertiary paediatric perspective. Emergency Medicine Australasia. 2017 Feb 1;29(1):77-82.

Cheek JA, Braitberg G, Craig S, West A. Why do children present to emergency departments? Exploring motivators and measures of presentation appropriateness for children presenting to a paediatric emergency department. Journal of Paediatrics and Child Health. 2017 May 1;53(5):451-7.