S Walsh

Intranasal fentanyl versus intravenous morphine in the emergency department treatment of severe painful sickle cell crises in children: Study protocol for a randomised controlled trial

BackgroundChildren with sickle cell disease (SCD) frequently and unpredictably present to the emergency department (ED) with pain. The painful event is the hallmark acute clinical manifestation of SCD, characterised by sudden onset and is usually bony in origin. This study aims to establish if 1.5mcg/kg of intranasal fentanyl (INF; administered via a Mucosal Atomiser Device, MAD™) is non-inferior to intravenous morphine 0.1 mg/kg in severe SCD-associated pain.Methods/designThis study is a randomised,double-blind, double-dummy active control trial of children (weighing more than 10 kg) between 1 year and 21 years of age with severe painful sickle cell crisis. Severe pain is defined as rated seven or greater on a 0 to 10 age-appropriate numeric pain scale or equivalent. The trial will be conducted in a single tertiary urban paediatric ED in Dublin, Ireland. Each patient will receive a single active agent and a single placebo via the intravenous and intranasal routes. All clinical and research staff, patients and parents will be blinded to the treatment allocation. The primary endpoint is severity of pain scored at 10 min from administration of the study medications. Secondary endpoints include pain severity measured at 0, 5, 15, 20, 30, 60 and 120 min after the administration of analgesia, proportion of patients requiring rescue analgesia and incidence of adverse events. The trial ends at 120 min after the administration of the study drugs. A clinically meaningful difference in validated pain scores has been defined as 13 mm. Setting the permitted threshold to 50% of this limit (6 mm) and assuming both treatments are on average equal, a sample size of 30 patients (15 per group) will provide at least 80% power to demonstrate that INF is non-inferior to IV morphine with a level of significance of 0.05.DiscussionThis clinical trial will inform of the role of INF 1.5mcg/kg via MAD in the acute treatment of severe painful sickle cell crisis in children in the ED setting.Trial registrationCurrent Controlled Trials ISRCTN67469672 and EudraCT no. 2011-005161-20

A review of a paediatric emergency department vaccination programme for patients at risk of allergy⁄anaphylaxis

Aim:  We sought to review the clinical outcomes of patients referred to our emergency department (ED) vaccination service for children with a history of allergy or anaphylaxis or in whom there was a concern of a significant adverse reaction.

Single dose oral dexamethasone versus multi-dose prednisolone in the treatment of acute exacerbations of asthma in children who attend the emergency department: study protocol for a randomized controlled trial

BackgroundAsthma is a major cause of pediatric morbidity and mortality. In acute exacerbations of asthma, corticosteroids reduce relapses, subsequent hospital admission and the need for ß2-agonist therapy. Prednisolone is relatively short-acting with a half-life of 12 to 36 hours, thereby requiring daily dosing. Prolonged treatment course, vomiting and a bitter taste may reduce patient compliance with prednisolone. Dexamethasone is a long-acting corticosteroid with a half-life of 36 to 72 hours. It is used frequently in children with croup and bacterial meningitis, and is well absorbed orally. The purpose of this trial is to examine whether a single dose of oral dexamethasone (0.3 mg/kg) is clinically non-inferior to prednisolone (1 mg/kg/day for three days) in the treatment of exacerbations of asthma in children who attend the Emergency Department.Methods/designThis is a randomized, non-inferiority, open-label clinical trial. After informed consent with or without assent, patients will be randomized to either oral dexamethasone 0.3 mg/kg stat or prednisolone 1 mg/kg/day for three days. The primary outcome measure is the comparison between the Pediatric Respiratory Assessment Measure (PRAM) across both groups on Day 4. The PRAM score, a validated, responsive and reliable tool to determine asthma severity in children aged 2 to 16 years, will be performed by a clinician blinded to treatment allocation. Secondary outcomes include relapse, hospital admission and requirement for further steroid therapy. Data will be analyzed on an intention-to-treat and a per protocol basis. With a sample size of 232 subjects (105 in each group with an estimated 10% loss to follow-up), we will be able to reject the null hypothesis - that the population means of the experimental and control groups are equal with a probability (power) of 0.9. The Type I error probability associated with this test (of the null hypothesis) is 0.05.DiscussionThis clinical trial may provide evidence that a shorter steroid course using dexamethasone can be used in the treatment of acute pediatric asthma, thus eliminating the issue of compliance to treatment.RegistrationISRCTN26944158 and EudraCT Number 2010-022001-18

G236 Prevalence and Management of Acute Pain in Children Attending Emergency Departments in Ireland Via Ambulance

Aims Pain is the commonest symptom in the emergency setting. It has previously been described that pre-hospital assessment of pain in children by paramedics is often inadequate and that pain severity is frequently underestimated. To date, there is no published data in Ireland on acute pain management in children, in the emergency setting. This study aims to describe the prevalence of acute pain in children presenting to emergency departments (EDs) in Ireland via ambulance, with reference to severity, aetiology, and efficacy of current pre-hospital analgesic interventions, prior to ED arrival. Methods A national prospective cross-sectional study was undertaken in 7 EDs over a 12-month period (1st November 2011 – October 31st 2012). Ethical approval was granted for this study. All children (<16 years) who attended the ED via ambulance with pain as a documented symptom during ambulance transfer were included. Patient demographics, cause of pain, vital signs (including pain scores), pre-hospital pain interventions, and initial ED management were recorded. Results 5,560 children were transported to the 7 EDs by ambulance over the study period. 2,450 (44%) had a documented complaint of pain on the ambulance patient care report form. Injury was implicated in over 2/3’s of cases. 60% were male with a mean age of 8 years (2 months-15 years). 24% of children had their pain formally assessed in the pre-hospital phase of care, of whom 2/3’s were recorded as experiencing acute moderate to severe pain. Younger age was associated with poorest pain management. 45% of children had no documented analgesic intervention prior to ED arrival. On ED arrival, 48% of children had their pain formally documented and 56% were administered analgesia. Conclusion The assessment and treatment of acute pain in children remains a significant problem in the emergency setting in Ireland. Further studies are required to formally delineate the barriers, as perceived by emergency healthcare providers, to managing acute pain in this vulnerable population. Additionally, alternative strategies must be explored both to augment the timely assessment of pain intensity, particularly in pre-verbal children, and facilitate the effective treatment of moderate to severe pain.

Fliker injuries in children

The Fliker, the new version of the foot-propelled scooter, has emerged as an increasingly popular recreational activity for children. This increase in popularity has led to a number of attendances to our tertiary paediatric emergency department (ED) with Fliker-associated injuries. The aim of this study was to examine the incidence and type of such injuries. This was a prospective descriptive study of all children (aged 0–16 years) attending the ED during a summer with Fliker-related injuries. Patients were identified through the ED Symphony Information System. Clinical notes of identified patients were investigated for the mechanism, location and type of injury. The clinical outcome of identified patients was also determined. Eighty patients, 39 boys (48.8%) and 41 girls (51.2%), were identified in the study period. The mean age of the patients was 7.9 years (range from 2 to 13 years). Upper limb injuries were most common, found in 33 (41.2%) children. There were 12 head injuries. The rest sustained lower limb injuries, soft tissue lacerations and dental injuries. The Fliker is one of a number of fad recreational activities to have emerged in recent times. Similar to some of its predecessors (e.g. Heelys, rollerblades), it is associated with a spectrum of injuries in children.

1619 Paediatric Painful Sickle Cell Crises: A Prospective Audit of Analgesic Practise in a Tertiary Paediatric Emergency Department

Introduction Although children with painful sickle cell crises (PSCC) frequently present to the Emergency Department (ED), pain in sickle cell disease is often under-recognised, under-treated and treatment may be delayed. We aimed to evaluate pain assessment and management in children presenting to the ED with PSCC. Methods A 12-month prospective descriptive study of acute pain management of PSCC at an urban tertiary paediatric ED. Pain was assessed by the triage nurse or physician using a validated age appropriate pain scale (Faces, Legs, Activity, Cry, Consolability (FLACC) Scale; Manchester Pain Ruler). Results There were 96 presentations in 66 patients with PSCC (Table 1). Nineteen (19.7%) patients recieved no pre-hospital analgesia. Abstract 1619 Table 1 Entire Cohort (n=96) Severe pain Cohort* (n=56) Moderate Cohort* (n=30) Triage Pain Score 7/10 (IQR 5–8) 8/10 (IQR 7–10) Pain Score at 60 minutes 5/10 (IQR 2.25–8) 7/10 (IQR 5–8) Cases in line with PED analgesia guidelines (%) 45% 95% Median time for opioid ‘breakthrough’ analgesia 87 minutes * severe pain defined as ≥ 7/10 and moderate pain as 3–6 on age-appropriate pain scale Conclusion PSCC pain is under-treated, under-monitored and adequate treatment of pain is delayed in our ED. Patients with severe pain appear at highest risk for treatment guideline violation. This is predominantly related to lack of opiate administration. An educational intervention, with/without the inclusion of an easily administered, fast-onset and short-acting opiate e.g. intranasal fentanyl, may decrease the time from ED arrival to effective pain relief.

1557 Implementation of a Procedural Sedation Programme in a Tertiary Paediatric Emergency Department

Background and Aims In the conduct of Paediatric Procedural Sedation (PPS) within the Emergency Department (ED) the combination of powerful drugs, variable competency levels and high staff turnover carry the potential for sedation-associated adverse events. Yet, currently, there is no set programme for education and accreditation of Irish ED staff in PPS. We describe the introduction of a structured educational programme for PPS within the ED for all ED clinical staff. Methods Prior to the introduction of the PPS programme in July 2011 a Sedation Committee was established comprising a core group of senior nurses and a Consultant in Emergency Medicine. The committee developed the PPS programme including key educational elements (Sedation Manual; Lecture; treatment order form and checklist; Parent Information Leaflet) and credentialing through multiple-choice questions (online and open-book), bedside teaching (2 scheduled practice sessions) and 2 competency assessments (final clinical/moulage). Results Since its inception (July 2011) a total of 48 ED staff members have started the PPS programme: 17 doctors (9 Registrars and 8 Senior House Officers) with 7 fully credentialled; 26 nursing staff (1 Clinical Nurse Manager (CNM) 3, 5 CNM2, 1 Advanced Nurse Practitioner (ANP) and 19 staff nurses) with 12 fully credentialled. Conclusions The introduction phase of our ED PPS, the first of its kind in Ireland, has been successful. As a result of the multidisciplinary development process, the programme will likely have broad applicability in different types of ED, and potentially other clinical areas, caring for children.

1578 The Correlation Between C-Reactive Protein and Serious Bacterial Infection in a Tertiary Paediatric Emergency Department: An Observational Case-Controlled Cohort Study

Background and Aims C-Reactive Protein (CRP) is a common component of the blood panel in children being investigated for the considered diagnosis of serious bacterial infection (SBI). We aimed to correlate CRP values to SBI in a paediatric population. Methods This is a retrospective study from 2007–2009 of all patients with CRP greater than 100mg/L. Controls were randomly selected age-matched patients with a CRP less than 100mg/L. SBI was defined as bacterial meningitis, bacteraemia, urinary tract infection, pneumonia, osteomyelitis, septic arthritis, appendicitis or abscess formation confirmed by microbiological investigations and/or supporting radiology and ultimate clinical diagnosis. Results 570/10,191 patients had a CRP > 100mg/L. 496 patients were controls 424 patients had SBI. A significant difference between the non-SBI group (n= 642), 35±68mg/L (median±standard deviation), compared to the SBI group (n=424), 141±87mg/L, existed. The absolute and ratio risk of SBI increased consistently with rising CRP values (Table 1). Abstract 1578 Table 1 Incidence, Absolute & Ratio Risks for SBI CRP Range Incidence of SBI Total cases Absolute Risk Ratio Risk 0–20 20 248 8% 0.08 21–100 39 181 21% 0.27 101–150 174 365 48% 0.92 151–200 83 134 62% 1.63 201–250 43 64 67% 2.03 251–300 44 52 84% 5.25 301+ 21 22 95% 21.2 Conclusion This multi-layered risk evaluation should aid the future management of children attending the PED being investigated for SBI.