Ffion Davies

Apparent life threatening events in infants presenting to an emergency department

Objective: To describe the aetiology and outcome of apparent life threatening events (ALTE) presenting to an emergency department (ED), and to assess the value of an initial investigation protocol. Design: A 12 month prospective study of infants under 1 year of age who presented to a childrens hospital ED after an ALTE. A standardised history sheet and initial investigation protocol were used. All infants were admitted to hospital and followed up at six months. Results: There were 65 infants recruited, median age 7 weeks. None had died at the time of writing. Diagnoses included gastro-oesophageal reflux n=17 (26%), pertussis, n=6 (9%), seizures, n=6 (9%), urinary tract infection (5), factitious illness (2), brain tumour, atrial tachycardia, persistent ductus arteriosus and opioid related apnoea. No diagnosis was reached in 15 cases (23%). Fifty seven (88%) had only one admission to hospital for ALTE. More serious diagnoses were associated with a presentation age over 2 months, abnormal initial clinical examination, and recurrent ALTE. Conclusions: ALTEs presenting to the ED may remain as a single, unexplained event or be attributable to numerous causes, ranging from minor to serious. Knowledge of the commoner causes and factors associated with higher risk could result in a more targeted approach, improving the decision making process and benefiting both infants and parents.

Consigning “brutacaine” to history: a survey of pharmacological techniques to facilitate painful procedures in children in emergency departments in the UK

Objective: To determine the proportion of emergency departments in the UK that use modern pharmacological methods of pain and anxiety control in children, such as analgesia with intranasal diamorphine, procedural sedation using ketamine or midazolam, and adrenaline–cocaine gel, TAC or LAT for anaesthetising wounds in children. Methods: A survey UK Emergency Departments conducted by email, post and telephone. Results: Of the 183 (70%) of UK Emergency Departments responding, sedation is achieved using ketamine in 27% and using midazolam in 54%. In 55% of emergency departments intranasal diamorphine is used for analgesia and 41% use at least one of the topical local-anaesthetic mixtures to anaesthetise wounds before suturing. Conclusions: About half of UK emergency departments use modern pharmacological methods of procedural pain control in children. There is still considerable potential to improve the management of pain in children.

Intranasal diamorphine for acute sickle cell pain

The painful crisis is the commonest acute presentation of sickle cell disease (SCD), yet effective pain control in hospital is often delayed, inadequate and dependent on injected opiates. Intranasal diamorphine (IND) has been used in paediatric emergency departments for management of acute pain associated with fractures, but the analgesic effect is short lived. We evaluated its efficacy and safety when given in combination with intravenous or oral morphine for rapid analgesia for children presenting to our emergency department with painful crisis of SCD. In phase 1, nine patients received IND plus intravenous morphine. In phase 2, 13 received IND plus oral morphine. There was a rapid improvement in pain score; the proportions in severe pain at t = 0, 15, 30 and 120 minutes in phase 1 were 78%, 11%, 0% and 11%, respectively; in phase 2, 77%, 30%, 15% and 0%, respectively. There were no serious side effects and questionnaire scores indicated that children found IND effective and acceptable. IND can be recommended for acute control of sickle pain in children presenting to hospital.

A profile of suspected child abuse as a subgroup of major trauma patients

Introduction Non-accidental injury (NAI) in children is an important cause of major injury. The Trauma Audit Research Network (TARN) recently analysed data on the demographics of paediatric trauma and highlighted NAI as a major cause of death and severe injury in children. This paper examined TARN data to characterise accidental versus abusive cases of major injury. Methods The national trauma registry of England and Wales (TARN) database was interrogated for the classification of mechanism of injury in children by intent, from January 2004 to December 2013. Contributing hospitals’ submissions were classified into accidental injury (AI), suspected child abuse (SCA) or alleged assault (AA) to enable demographic and injury comparisons. Results In the study population of 14 845 children, 13 708 (92.3%, CI 91.9% to 92.8%) were classified as accidental injury, 368 as alleged assault (2.5%, CI 2.2% to 2.7%) and 769 as SCA (5.2%, CI 4.8% to 5.5%). Nearly all cases of severely injured children suffering trauma because of SCA occurred in the age group of 0–5 years (751 of 769, 97.7%), with 76.3% occurring in infants under the age of 1 year. Compared with accidental injury, suspected victims of abuse have higher overall injury severity scores, have a higher proportion of head injury and a threefold higher mortality rate of 7.6% (CI 5.51% to 9.68%) vs 2.6% (CI 2.3% to 2.9%). Conclusions This study highlights that major injury occurring as a result of SCA has a typical demographic pattern. These children tend to be under 12 months of age, with more severe injury. Understanding these demographics could help receiving hospitals identify children with major injuries resulting from abuse and ensure swift transfer to specialist care.

Nasal bleeding and non-accidental injury in an infant

Bleeding from the nose has been a point of controversy in the field of child protection in the UK in recent years. Epistaxis in childhood is common but is unusual in the first year of life. Oronasal blood in infancy has been proposed as a marker of child abuse in this age group, but despite this widely held belief, there is a lack of published evidence in this area. The case is reported of an infant who presented at one month of age with serious inflicted injuries, who had been seen in the emergency department only 13 days previously with a “spontaneous” self-limiting nose bleed.

Prediction of severe bacterial infection in children with an emergency department diagnosis of infection

Objective To determine the relationship between near-patient-test (NPT) lactate, white blood cell count (WBC) and C-reactive protein (CRP) and severe bacterial infection (SBI) in children presenting to the emergency department (ED) with infection. Methods An observational cohort study was undertaken in a paediatric emergency department of a large urban teaching hospital. Data were collected from January 2007 until December 2007. Inclusion criteria were age <16 years, blood test including NPT lactate obtained in the ED and infection-related ED diagnosis. Patients were pre-assigned to risk groups according to their NPT lactate, WBC and CRP. Results 506 children were included in the study, of which 42 (8.3%) had SBI. NPT lactate, WBC and CRP were significantly higher in the SBI cohort. High-risk NPT lactate (≥4 mmol/l) had a sensitivity of 38.1% (95% CI 23.6% to 54.4%) and a specificity of 89.7% (95% CI 86.5% to 92.3%); high-risk WBC (<5 or ≥15×109/l) had a sensitivity of 51.2% (95% CI 35.1% to 67.1%) and a specificity of 73.8% (95% CI 69.4% to 77.8%); and high-risk CRP (≥50 mg/l) had a sensitivity of 36.8% (95% CI 21.8% to 54.1%) and a specificity of 83.6% (95% CI 79.4% to 87.2%) for SBI. All three high-risk markers combined yielded a sensitivity of 5.3% (95% CI 1.5% to 17.3%) and a specificity of 99.2% (95% CI 97.6% to 99.7%) for SBI. Conclusion The data from our study suggest that NPT lactate provides early diagnostic information about the risk of SBI in children presenting to the ED with a suspected infection. Combining NPT lactate with WBC and CRP resulted in a promising rule-in-tool for SBI in children in the ED which, with prospective validation, has the potential to aid early identification of SBI in children.

O-009a The Paediatric Observation Priority Score (pops): Outcomes Of 24000 Patients

Background The Paediatric Observation Priority Score (POPS) (see Figure) has been designed as a triage tool and illness identification system to aid disposition and discharge decisions. Methods A unique data-collection method was set up whereby the key parameters of POPS were inputted onto a web-based data entry sheet. All children 0–15 presenting with any condition were included except those presenting straight to the resuscitation room. Data was collated with the hospital’s Emergency Department Information System and information from inpatient hospital systems. Results After data cleaning 24068 records were available for review between the period of August 2012 and December 2013. 2870 patients were admitted (11.9%). The majority of patients (16475) were POPS 0 (Table 1) and of these 794 (4.8%) were admitted to the hospital. Only 11 children discharged with POPS 0 returned to be admitted and required further definitive management. There was a correlation between initial POPS and average hospital stay (Pearsons correlation - 0.83, r2=0.92). The receiver operating characteristic (ROC) curve was 0.802 for POPS values sectioned into categories {0, 1–2, 3–4, 5–7 and 8+} at predicting admission. Abstract O-009a Table 1 Conclusion POPS demonstrates utility as a patient safety system and a means to plan resources. The ROC is comparable with paediatric early warning scores systems utilised in Children’s Emergency Departments. There are significant risks in managing the acutely ill child but the introduction of POPS may assist in reducing unnecessary admission and prevent episodes of missed or incorrect diagnosis. Abstract O-009a Figure 1

Minamata disease: A 1989 update on the mercury poisoning epidemic in Japan

Minamata disease first became evident in Japan in 1956 and was caused by methyl mercury exposure. Over 20,000 people are now thought to have been affected. This article compares the situation immediately following the initial discovery with that now prevalent.

Scoring systems in paediatric emergency care: Panacea or paper exercise?

Scoring systems to recognise the most ill patients, or those at risk of deterioration, are increasingly utilised in hospitals that look after paediatric inpatients. There have been efforts to implement these systems in emergency and urgent care settings, but they have yet unproven value. This is because the child or young person presenting acutely is a different cohort than the ‘treated’ ward‐based group. The majority of children presenting to emergency and urgent care settings are discharged home, and so, scoring systems need to recognise the most unwell but also assist in safe and appropriate discharge as well as highlighting those patients in need of more senior review. This article explores this conundrum, suggesting how cognitive factors have a role to play, and how scoring systems can have wider effects than just individual patient care.

028 Determining the effect of objective and subjective criteria on a risk assessment tool in a Children's Emergency Department

Objectives and Background Children with serious illness can be difficult to spot, especially for non-experienced staff. Although adult “early warning scores” are now commonly used in Emergency Departments (ED), there is no such system for children. The Paediatric Observation Priority Score (POPS) is a physiological and observational scoring system (range 0–16) designed for use by healthcare professionals of varying clinical experience at initial assessment in our ED. The aim is to use POPS to identify sick children, aid healthcare professionals in confidently discharging or re-directing patients and providing a departmental level of acuity to aid resource allocation. A first phase of the validation process examined the utility of the more subjective criteria of POPS (level of alertness, work of breathing, nursing concern and relevant background history) against the physiological criteria (heart rate, breathing rate, saturations and temperature) in determining admission to the childrens hospital assessment unit from the ED. Methods Convenience sample case note review of attendances to the ED, analysing patient discharge disposition against initial POPS recorded. Results 942 (injuries not included) presentations from 2009 to 2010 were included in the study with an overall admission rate of 36% (339/942). RR of admission of admission with a POPS of >0 was 2.1 (CI 1.6 to 2.7). Conclusion The large range of confounding influences affecting the admission of children to hospital makes an initial point of care assessment predictive model difficult. This work demonstrated interesting variation in performance of the component sections of the POPS score. The use of subjective, user dependant factors, may inhibit the performance of physiological values which have traditionally be used in aiding illness recognition. Further work is ongoing to improve the performance of the tool as an adjunct to risk assessment and resource allocation.Abstract 028 Table 1 Ability to predict admission Sensitivity Specificity Positive predictive value Negative predictive value POPS>0 0.82 0.38 0.42 0.79 Physiological values only (any score>0) 0.74 0.45 0.43 0.75 Subjective criteria only (any score>0) 0.66 0.67 0.53 0.78 Any nursing concern 0.59 0.74 0.57 0.76