Ed Oakley

Reduction of paediatric in-patient cardiac arrest and death with a medical emergency team: preliminary results

Aims: To determine the impact of a paediatric medical emergency team (MET) on cardiac arrest, mortality, and unplanned admission to intensive care in a paediatric tertiary care hospital. Methods: Comparison of the retrospective incidence of cardiac arrest and death during 41 months before introduction of a MET service with the prospective incidence of these events during 12 months after its introduction. Comparison of transgression of MET call criteria in patients who arrested and died before and after introduction of MET. Results: Cardiac arrest decreased from 20 among 104 780 admissions (0.19/1000) to 4 among 35 892 admissions (0.11/1000) (risk ratio 1.71, 95% CI 0.59 to 5.01), while death decreased from 13 (0.12/1000) to 2 (0.06/1000) during these periods (risk ratio 2.22, 95% CI 0.50 to 9.87). Unplanned admissions to intensive care increased from 20 (SD 6) to 24 (SD 9) per month. The incidence of transgression of MET call criteria in patients who arrested decreased from 17 to 0 (risk difference 0.16/1000, 95% CI 0.09 to 0.24), and in those who died, decreased from 12 to 0 (risk difference 0.11/1000, 95% CI 0.05 to 0.18) after introduction of MET. Conclusions: Introduction of a medical emergency team service was coincident with a reduction of cardiac arrest and mortality and a slight increase in admissions to intensive care.

Using Video Recording to Identify Management Errors in Pediatric Trauma Resuscitation

OBJECTIVE. To determine the ability of video recording to identify management errors in trauma resuscitation and to compare this method with medical record review. METHOD. The resuscitation of children who presented to the emergency department of the Royal Childrens Hospital between February 19, 2001, and August 18, 2002, for whom the trauma team was activated was video recorded. The tapes were analyzed, and management was compared with Advanced Trauma Life Support guidelines. Deviations from these guidelines were recorded as errors. Fifty video recordings were analyzed independently by 2 reviewers. Medical record review was undertaken for a cohort of the most seriously injured patients, and errors were identified. The errors detected with the 2 methods were compared. RESULTS. Ninety resuscitations were video recorded and analyzed. An average of 5.9 errors per resuscitation was identified with this method (range: 1–12 errors). Twenty-five children (28%) had an injury severity score of >11; there was an average of 2.16 errors per patient in this group. Only 10 (20%) of these errors were detected in the medical record review. Medical record review detected an additional 8 errors that were not evident on the video recordings. Concordance between independent reviewers was high, with 93% agreement. CONCLUSIONS. Video recording is more effective than medical record review in detecting management errors in pediatric trauma resuscitation. Management errors in pediatric trauma resuscitation are common and often involve basic resuscitation principles. Resuscitation of the most seriously injured children was associated with fewer errors. Video recording is a useful adjunct to trauma resuscitation auditing.

High-Concentration Nitrous Oxide for Procedural Sedation in Children: Adverse Events and Depth of Sedation

OBJECTIVE. Nitrous oxide is an attractive agent for procedural sedation and analgesia in the emergency department; however, there are limited safety data for high-concentration continuous-flow nitrous oxide (50%–70%) and its use in young children. We set out to characterize the depth of sedation and incidence of adverse events associated with various concentrations of nitrous oxide used in a pediatric emergency department. METHODS. This was a prospective observational study of nitrous oxide use for procedural sedation and analgesia in a tertiary childrens hospital emergency department. Nitrous oxide concentration, adverse events, and sedation depth were recorded. Adverse events were categorized as mild or serious. Sedation depth was recorded on a sedation scale from 0 to 6. RESULTS. A total of 762 patients who were aged 1 to 17 years received nitrous oxide during the 2-year study period. A total of 548 (72%) received nitrous oxide 70%, and 101 (13%) received nitrous oxide 50%. Moderate or deep sedation with scores of ≤2 occurred in 3% of patients who had received nitrous oxide 70% and no patients who had received nitrous oxide 50%. Mean sedation scores were 4.4 at nitrous oxide 70% and 4.6 at nitrous oxide 50%. Sixty-three (8.3%) patients sustained 70 mild and self-resolving adverse events, most of which were vomiting (5.7%); 2 (0.2%) patients had serious adverse events. There was no significant difference in adverse events rates between nitrous oxide 70% (8.4%) and nitrous oxide 50% (9.9%). There was no significant difference in the percentage of deep sedation when children who were ≤3 years of age (2.9%) were compared with older children (2.8%). CONCLUSIONS. In this largest prospective emergency department series, high-concentration continuous-flow nitrous oxide (70%) was found to be a safe agent for procedural sedation and analgesia when embedded in a comprehensive sedation program. Nitrous oxide also seems safe in children aged 1 to 3 years.

Preprocedural fasting state and adverse events in children receiving nitrous oxide for procedural sedation and analgesia.

Study Objective: Established fasting guidelines for analgesia and sedation are difficult to follow in the emergency department (ED), and the association between preprocedural fasting and adverse events has been questioned. We characterize the fasting status of patients receiving procedural sedation and analgesia with nitrous oxide (N2O) in a pediatric ED and assess the relationship between fasting status and adverse events. Methods: A prospective case series was conducted in a childrens hospital ED over an 8-month period. Patients receiving N2O for procedural sedation and analgesia were enrolled and followed up by telephone call. Preprocedural fasting state and adverse events, as well as N2O concentration, adjunctive drugs, and deepest level of sedation, were recorded. Adverse events were analyzed in relation to fasting status. Results: Two hundred twenty children who underwent procedural sedation and analgesia with N2O were enrolled. Fasting status was obtained in 218 patients (99.1%). Of these, 155 (71.1%; 95% confidence interval [CI], 64.5%-77.0%) did not meet fasting guidelines for solids There were no serious adverse events and no episodes of aspiration (1-sided 97.5% CI, 0%-1.7%). While in the ED, 46 minor adverse events occurred in 37 patients (16.8%; 95% CI, 12.1%-22.4%). Emesis occurred in 15 patients (7%), including 4 (6.3%; 95% CI, 1.8%-15.5%) of 63 patients who met and in 11 (7.1%; 95% CI, 3.6%-12.3%) of 155 patients who did not meet fasting guidelines for solids. There was no significant difference in median fasting duration between patients with and without emesis. Conclusion: Seventy-one percent of patients undergoing ED procedural sedation and analgesia with N2O did not meet established fasting guidelines. In this series, there was no association between preprocedural fasting and emesis. There were no serious adverse events.

Comparing CATCH, CHALICE and PECARN clinical decision rules for paediatric head injuries.

Many children present to emergency departments following head injury (HI), with a small number at risk of avoidable poor outcome. Difficulty identifying such children, coupled with increased availability of cranial CT, has led to variation in practice and increased CT rates. Clinical decision rules (CDRs) have been derived for paediatric HI but there is no published comparison to assist in deciding which to implement. The content of the three of highest quality and accuracy are described and compared. Systematic reviews of paediatric HI CDRs were published in 2009 and 2011. To identify CDRs published since the most recent review, key databases were searched, selecting studies which included CDRs involving children aged 0–18 years with a history of HI. Quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies Tool, and performance evaluated by reported accuracy. Three high quality CDRs were identified: CATCH (Canadian Assessment of Tomography for Childhood Head Injury) CHALICE (Childrens Head Injury Algorithm for the Prediction of Important Clinical Events) and PECARN (Paediatric Emergency Care Applied Research Network). All were derived with high methodological standards but differed in key areas, including study population, outcomes and severity of HI. Each stated different predictor variables and only PECARN provided a separate algorithm for young children. CATCH and CHALICE identify children requiring CT and PECARN those who do not. All perform with high sensitivity and low specificity. PECARN is the only validated CDR, and none has undergone impact analysis. These three CDRs should undergo validation and comparison in a single population, with analysis of their impact on practice and financial implications, to aid relevant bodies in deciding which to implement.

Contamination rates of different urine collection methods for the diagnosis of urinary tract infections in young children: an observational cohort study.

Aims:  The optimal method for diagnostic collection of urine in children is unclear. National Institute of Health and Clinical Excellence recommend specimens taken by clean catch urine (CCU) for identification of urinary tract infection (UTI). We investigated contamination rates for CCU, suprapubic aspiration (SPA), catheter specimen urine (CSU) and bag specimen urine (BSU) collections.

Limited analgesic efficacy of nitrous oxide for painful procedures in children

Study objective: Nitrous oxide (N2O) is an attractive agent for procedural analgesia and sedation of children in the emergency department (ED). Despite increasing use, efficacy data for painful procedures are limited. This study aimed to determine pain scores during ED procedural sedation with N2O in the ED setting. Methods: Prospective observational study of N2O use as a sole agent for procedural analgesia at a tertiary children’s hospital ED. Pain scores were obtained from patients and parents using visual analogue or faces scales, as appropriate. Parent and staff satisfaction with sedation and analgesia were assessed. Results: 124 children aged 1–17 years (mean 8.1) underwent procedural analgesia with N2O for 131 procedures. Most procedures were orthopaedic (44%) or laceration repair (30%). In 51% of patients (95% CI 42% to 60 to 23%) pain scores remained unchanged and in 34% (95% CI 26% to 43%) pain scores increased. Overall, 34% (95% CI 26% to 43%) patients had intraprocedural scores of 50 mm or greater and 21% (95% CI 14% to 29%) had pain scores of 70 mm or greater. Some procedures such as fracture reduction had a larger proportion of patients with high pain scores or 50 mm or greater (45%) and 70 mm or greater (29%). Staff rated both sedation and analgesia as “adequate” in 92%. Parents contacted in follow-up were satisfied or very satisfied with procedures in 96% and sedations in 93%. Conclusion: Data indicate that parents and staff are generally satisfied with N2O for procedural use in the ED. The efficacy of N2O as a sole agent in very painful procedures is limited.

Sub‐dissociative dose intranasal ketamine for limb injury pain in children in the emergency department: A pilot study

The present study aims to conduct a pilot study examining the effectiveness of intranasal (IN) ketamine as an analgesic for children in the ED.

Nasogastric hydration versus intravenous hydration for infants with bronchiolitis: a randomised trial.

BACKGROUND Bronchiolitis is the most common lower respiratory tract infection in infants and the leading cause of hospital admission. Hydration is a mainstay of treatment, but insufficient evidence exists to guide clinical practice. We aimed to assess whether intravenous hydration or nasogastric hydration is better for treatment of infants. METHODS In this multicentre, open, randomised trial, we enrolled infants aged 2-12 months admitted to hospitals in Australia and New Zealand with a clinical diagnosis of bronchiolitis during three bronchiolitis seasons (April 1-Oct 31, in 2009, 2010, and 2011). We randomly allocated infants to nasogastric hydration or intravenous hydration by use of a computer-generated sequence and opaque sealed envelopes, with three randomly assigned block sizes and stratified by hospital site and age group (2-<6 months vs 6-12 months). The primary outcome was length of hospital stay, assessed in all randomly assigned infants. Secondary outcomes included rates of intensive-care unit admission, adverse events, and success of insertion. This trial is registered with the Australian and New Zealand clinical trials registry, ACTRN12605000033640. FINDINGS Mean length of stay for 381 infants assigned nasogastric hydration was 86·6 h (SD 58·9) compared with 82·2 h (58·8) for 378 infants assigned intravenous hydration (absolute difference 4·5 h [95% CI -3·9 to 12·9]; p=0·30). Rates of admission to intensive-care units, need for ventilatory support, and adverse events did not differ between groups. At randomisation, seven infants assigned nasogastric hydration were switched to intravenous hydration and 56 infants assigned intravenous hydration were switched to nasogastric hydration because the study-assigned method was unable to be inserted. For those infants who had data available for successful insertion, 275 (85%) of 323 infants in the nasogastric hydration group and 165 (56%) of 294 infants in the intravenous hydration group required only one attempt for successful insertion. INTERPRETATION Intravenous hydration and nasogastric hydration are appropriate means to hydrate infants with bronchiolitis. Nasogastric insertion might require fewer attempts and have a higher success rate of insertion than intravenous hydration. FUNDING Australian National Health and Medical Research Council, Samuel Nissen Charitable Foundation (Perpetual), Murdoch Childrens Research Institute, Victorian Government.

Accuracy of PECARN, CATCH, and CHALICE head injury decision rules in children: a prospective cohort study

BACKGROUND Clinical decision rules can help to determine the need for CT imaging in children with head injuries. We aimed to validate three clinical decision rules (PECARN, CATCH, and CHALICE) in a large sample of children. METHODS In this prospective observational study, we included children and adolescents (aged <18 years) with head injuries of any severity who presented to the emergency departments of ten Australian and New Zealand hospitals. We assessed the diagnostic accuracy of PECARN (stratified into children aged <2 years and ≥2 years), CATCH, and CHALICE in predicting each rule-specific outcome measure (clinically important traumatic brain injury [TBI], need for neurological intervention, and clinically significant intracranial injury, respectively). For each calculation we used rule-specific predictor variables in populations that satisfied inclusion and exclusion criteria for each rule (validation cohort). In a secondary analysis, we compiled a comparison cohort of patients with mild head injuries (Glasgow Coma Scale score 13-15) and calculated accuracy using rule-specific predictor variables for the standardised outcome of clinically important TBI. This study is registered with the Australian New Zealand Clinical Trials Registry, number ACTRN12614000463673. FINDINGS Between April 11, 2011, and Nov 30, 2014, we analysed 20 137 children and adolescents attending with head injuries. CTs were obtained for 2106 (10%) patients, 4544 (23%) were admitted, 83 (<1%) underwent neurosurgery, and 15 (<1%) died. PECARN was applicable for 4011 (75%) of 5374 patients younger than 2 years and 11 152 (76%) of 14 763 patients aged 2 years and older. CATCH was applicable for 4957 (25%) patients and CHALICE for 20 029 (99%). The highest point validation sensitivities were shown for PECARN in children younger than 2 years (100·0%, 95% CI 90·7-100·0; 38 patients identified of 38 with outcome [38/38]) and PECARN in children 2 years and older (99·0%, 94·4-100·0; 97/98), followed by CATCH (high-risk predictors only; 95·2%; 76·2-99·9; 20/21; medium-risk and high-risk predictors 88·7%; 82·2-93·4; 125/141) and CHALICE (92·3%, 89·2-94·7; 370/401). In the comparison cohort of 18 913 patients with mild injuries, sensitivities for clinically important TBI were similar. Negative predictive values in both analyses were higher than 99% for all rules. INTERPRETATION The sensitivities of three clinical decision rules for head injuries in children were high when used as designed. The findings are an important starting point for clinicians considering the introduction of one of the rules. FUNDING National Health and Medical Research Council, Emergency Medicine Foundation, Perpetual Philanthropic Services, WA Health Targeted Research Funds, Townsville Hospital Private Practice Fund, Auckland Medical Research Foundation, A + Trust.