Nicholas Cheng

Predictors of severe H1N1 infection in children presenting within Pediatric Emergency Research Networks (PERN): retrospective case-control study.

Objective To identify historical and clinical findings at emergency department presentation associated with severe H1N1 outcome in children presenting with influenza-like illness. Design Multicentre retrospective case-control study. Setting 79 emergency departments of hospitals associated with the Pediatric Emergency Research Networks in 12 countries. Participants 265 children (<16 years), presenting between 16 April and 31 December 2009, who fulfilled Centers for Disease Control and Prevention criteria for influenza-like illness and developed severe outcomes from laboratory confirmed H1N1 infection. For each case, two controls presenting with influenza-like illness but without severe outcomes were included: one random control and one age matched control. Main outcome measures Severe outcomes included death or admission to intensive care for assisted ventilation, inotropic support, or both. Multivariable conditional logistic regression was used to compare cases and controls, with effect sizes measured as adjusted odds ratios. Results 151 (57%) of the 265 cases were male, the median age was 6 (interquartile range 2.3-10.0) years, and 27 (10%) died. Six factors were associated with severe outcomes in children presenting with influenza-like illness: history of chronic lung disease (odds ratio 10.3, 95% confidence interval 1.5 to 69.8), history of cerebral palsy/developmental delay (10.2, 2.0 to 51.4), signs of chest retractions (9.6, 3.2 to 29.0), signs of dehydration (8.8, 1.6 to 49.3), requirement for oxygen (5.8, 2.0 to 16.2), and tachycardia relative to age). Conclusion These independent risk factors may alert clinicians to children at risk of severe outcomes when presenting with influenza-like illness during future pandemics.

Femoral nerve block for femoral shaft fractures in a paediatric Emergency Department: can it be done better?

Background: The relatively simple technique of administering a femoral nerve block is known to be quick, safe and effective in providing prolonged analgesia to children with femoral shaft fracture. Although medical literature supports its use in the emergency setting, no studies have been conducted on how this is undertaken in practice. Objective: The aim of this study is to describe the practice of femoral nerve block in previously well children who present to our Emergency Department with femoral shaft fracture. Setting: This study was conducted at the Emergency Department of a tertiary paediatric hospital in Sydney, Australia. Methods: A retrospective descriptive study was conducted by gathering data on all patients presenting to the Emergency Department between 1 January 1996 and 1 July 2001 with traumatic fracture to the femoral shaft. Whether femoral nerve block had been performed in the emergency setting; the time taken for femoral nerve block to be performed; the type of local anaesthetic used; the dose of local anaesthetic administered, and the level of training and area of expertise of doctors performing the femoral nerve block were determined from the clinical records. One-way analysis of variance and Students t-tests were conducted to compare the average dosages of local anaesthetic used by the different medical sub-specialities involved. Students t-tests were applied to analyse the time differences for performing femoral nerve block between emergency- and non-emergency-based medical staff. Results: The majority (111) of the 117 patients who met the inclusion criteria for the study had isolated femoral shaft fractures (94.9%). Femoral nerve blocks were performed in 97 of our study patients (82.9%). No correlation was found between the age of the child and the time taken for a femoral nerve block. In 76 cases in which a femoral nerve block was given (64.9%), a member of staff external to the Emergency Department performed the procedure. The average time taken for a femoral nerve block to be performed for non-Emergency Department medical staff was significantly longer than for Emergency Department medical staff. In only 37 cases (31.9%), was a femoral nerve block administered within an hour of the time of triage. Doses used by non-anaesthetists were lower than those used by anaesthetists. Conclusion: There is unnecessary delay in carrying out this procedure for children with fractures to the femoral shaft. A significant degree of reliance on staff external to the Emergency Department was reported. This paper supports increased training and supervision to promote the more widespread and prompt use of femoral nerve blocks as an important standard of care for the Emergency Department.

Primary cardiac arrest following sport or exertion in children presenting to an emergency department: chest compressions and early defibrillation can save lives, but is intravenous epinephrine always appropriate?

Objectives The objective of this study was to describe the characteristics and outcome of pediatric patients presenting to an emergency department (ED) following out-of-hospital primary cardiac arrest (OHPCA), to determine if long-term survival is influenced by specific resuscitation interventions. Methods This was a prospective observational study of cases of OHPCA during sport or exertion in young patients presenting to an ED over a 5-year period. Cases were identified from a resuscitation database, which documented patient demographics, nature of event, emergency treatment, response times, and clinical progress. These data were analyzed to determine outcomes. Results Nine children were identified who presented following OHPCA during the study period. The mean age was 10.7 (±4.2) years. All were subsequently diagnosed with an underlying primary cardiac disorder. Six patients (66.6%) survived to make a full recovery. All patients who survived had received early chest compressions (within 5 minutes) and early defibrillation (within 10 minutes). The initial cardiac arrest rhythm in all survivors had been an electrically cardiovertable rhythm. Five (83%) of the 6 survivors did not receive epinephrine during resuscitation. Conclusions The importance of early chest compressions and defibrillation in collapsed young athletes is highlighted in this report. These interventions can result in full long-term neurological recovery. Use of epinephrine in these patients may be dangerous. We suggest that special consideration should be given to this subgroup of patients in the development of future resuscitation guidelines.

Effect of a holiday service reduction period on a hospital’s emergency department access block

Objective:  To study the effect of holiday service reductions, consisting of bed and theatre closures, in a tertiary paediatric hospital on various measures of ED occupancy, including access block.

PREDICT prioritisation study: establishing the research priorities of paediatric emergency medicine physicians in Australia and New Zealand

Background The Paediatric Research in Emergency Departments International Collaborative (PREDICT) performs multicentre research in Australia and New Zealand. Research priorities are difficult to determine, often relying on individual interests or prior work. Objective To identify the research priorities of paediatric emergency medicine (PEM) specialists working in Australia and New Zealand. Methods Online surveys were administered in a two-stage, modified Delphi study. Eligible participants were PEM specialists (consultants and senior advanced trainees in PEM from 14 PREDICT sites). Participants submitted up to 3 of their most important research questions (survey 1). Responses were collated and refined, then a shortlist of refined questions was returned to participants for prioritisation (survey 2). A further prioritisation exercise was carried out at a PREDICT meeting using the Hanlon Process of Prioritisation. This determined the priorities of active researchers in PEM including an emphasis on the feasibility of a research question. Results One hundred and six of 254 (42%) eligible participants responded to survey 1 and 142/245 (58%) to survey 2. One hundred and sixty-eight (66%) took part in either or both surveys. Two hundred forty-six individual research questions were submitted in survey 1. Survey 2 established a prioritised list of 35 research questions. Priority topics from both the Delphi and Hanlon process included high flow oxygenation in intubation, fluid volume resuscitation in sepsis, imaging in cervical spine injury, intravenous therapy for asthma and vasopressor use in sepsis. Conclusion This prioritisation process has established a list of research questions, which will inform multicentre PEM research in Australia and New Zealand. It has also emphasised the importance of the translation of new knowledge.

Pediatric Emergency Research Networks: a global initiative in pediatric emergency medicine.

Objectives The objectives of the Pediatric Emergency Research Networks (PERN) meeting were to (i) learn about each of the participating networks missions, goals, and infrastructure; (ii) share important contributions that each network has made to the creation of new knowledge; (iii) discuss ‘best practices’ to improve each networks effectiveness and (iv) explore the potential for a collaborative research project as proof-of-concept that would help promote quality of care of the acutely ill and injured child/youth globally. Methods In October 2009 a multiday meeting was attended by 18 delegates representing the following pediatric emergency medicine research networks: Pediatric Emergency Medicine Collaborative Research Committee (USA); Pediatric Emergency Care Applied Research Network (USA); Pediatric Emergency Research of Canada (Canada); Pediatric Research in Emergency Departments International Collaborative (Australia and New Zealand); and Research in European Pediatric Emergency Medicine (15 countries in Europe and the Middle East). Results The inaugural meeting of PERN showed that there is a common desire for high-quality research and the dissemination of this research to improve health and outcomes of acutely ill and injured children and youths throughout the world. At present, the PERN group is in the final stages of developing a protocol to assess H1N1 risk factors with the collection of retrospective data. Conclusion Several members of PERN will be gathering at the International Conference on Emergency Medicine in Singapore, where the group will be presenting information about the H1N1 initiative. The PERN group is planning to bring together all five networks later in 2010 to discuss future global collaborations.

Bell's palsy in children: Current treatment patterns in Australia and New Zealand. A PREDICT study

The aetiology and clinical course of Bells palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bells palsy in children. The aim of the study was to assess current practice in paediatric Bells palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT).

Unexpectedly high aminoglycoside level in a neonate with congenital hypopituitarism.

Meconium peritonitis is a sterile chemical peritonitis due to leakage of meconium from the bowel in utero. Perforation usually results from obstruction, which can be due to volvulus, intestinal atresia or inspissated meconium associated with cystic fibrosis or vascular compromise of the gut. Occasionally the perforation is idiopathic; gastrointestinal disorder is evident at birth. Although the processus vaginalis is still patent in 80–90% of full-term babies, extension of intra-abdominal pathology into the scrotum is relatively rare. The processus vaginalis forms by the sixth foetal month and enters the scrotum by the seventh month. Subsequently the testes descend into the scrotum. The processus vaginalis remains patent until birth or shortly thereafter, leaving the residual tunica vaginalis. Following an in utero bowel perforation, a fluid meconium-filled ‘hydrocele’ may thus be present at birth. We present a typical giant meconium hydrocele with ascitis of unknown aetiology not reported in our country. A full-term, 1-day-old male baby weighing 2.7 kg presented to us at 36 h after birth with bilateral scrotal swelling of 8 ¥ 6 ¥ 5 cm; soft, cystic, normal colour of overlying mature scrotal skin; no impulse on crying; non-compressible, positive transillumination in the root of scrotum and negative below that (Fig. 1). The baby passed urine normally on the first day of life but had not passed meconium since birth. Abdomen was distended and free fluid was present. The general condition was poor and respiratory rate was high. The baby was put on intravenous fluid and antibiotics. X-ray of the abdomen was suggestive of pneumoperitonium with opacity of scrotum. Abdominal paracentesis drained 100 ml of meconium stained fluid following which explortory laparotomy was done. On exploration, the peritoneum was filled with liquefied meconium, which was communicated with scrotum via the inguinal canal but the perforation site was not detected in the whole gastrointestinal tract. The peritoneal cavity was cleaned by normal saline and antibiotics solution and the bilateral inguinal ring was closed by absorbable suture after aspiration of fluid from the scrotal sac. The abdomen was closed after placement of a drain in the pelvis. The baby passed stool after 3 days and the drain was removed after 5 days. Oral feed was allowed on the seventh day and the baby was discharged well on the 10th day. The baby was well in the follow-up. A patent processus vaginalis in the male foetus may lead to the migration of meconium into the scrotum, and these infants can present with soft meconium-filled hydrocele at birth. Local tissue reaction during the first several weeks of life results in calcification of this hydrocele into hard, tumour-like lesions that may mimic testicular neoplasia. The simple bilateral hydrocele can be differentiated from meconium hydrocele and testicular neoplasia clinically, in the form of the fluctuation and transillumination test and also by ultrasonological examination of the scrotum. Tanaka et al. noted that operation of meconium peritonitis was difficult because the patient’s general condition was poor, and dissection of the adhesion was difficult, owing to severe inflammation and bleeding. The patient undergoing an ultrasoundguided drainage of the cystic meconium peritonitis before surgery had better outcome. In our case, the cause of bilateral meconium hydrocele may be an antenatal perforation in the gastrointestinal tract due to unknown cause becomes sealed off in later period of gestation. It is mandatory to rule out this lifethreatening condition by antenatal sonography, post-natal clinical examination and radiological study to confirm the diagnosis of gastrointestinal perforation.