Paediatric Emergencies Update 2024 – Noosa Day 2 & 3

Back for day 2 and day 3 at the PEM Colloquium, kicking off with:

Marlene Soma – ENT Emergencies

Auricular haematoma is more common in males than females and associated with sporting injuries, repetitive blows, bleeding issues, spontaneous (which is rare) or NAI. The risk is permanent cauliflower deformity with neocartilage formation. Drainage can be undertaken in the ED but sometimes aspiration is not enough; in kids, more often it is done open under GA. The incision is usually made along the fold for cosmesis and the structure of the pinna is retained with the elimination of headspace to preserve the ear’s appearance. Where there is perichondritis, it is usually pseudomonas so oral Ciprofloxacin is the antibiotic of choice.

Removal of ear FBs is not generally an emergency unless it is a button battery; insects are uncomfortable and so are often prioritised for early removal. Sedation might be needed if safer – Marlene had some great tips and tricks.

Otitis externa is usually moisture associated (eg swimming, irrigation, hearing aid). It can cause severe pain and is commonly caused by Pseudomonas, Staph and other bacteria. Management involves analgesia, avoidance of water exposure, removal of debris, otowick or other wicks can be used, topical antimicrobial (this can be cream, ointment or drops +/- steroid drops). Cipro is the only one that says it is specifically safe for perforation so probably gets overused; swabs can be helpful for ongoing treatment.

Otitis media is a very common presentation to the PED (one study found 6.8% of visits). On otoscopy exam you would typically see a bulging TM, often injected and with a milky appearance. Perforations are not usually small round holes but have jagged edges. Glue ear (otitis media with effusion) has a different appearance with the drum retracted. There are not usually ear specific symptoms in glue ear but deafness or reduced hearing is the predominant symptom. Chronic suppurative otitis media is more common in some populations, particularly First Nations (Aboriginal and Torres Strait Islander) people in Australia. Typical organisms are viral, Strep pneumonia, non-typeable Haem influenza, Moraxhella catarrhalis. Antibiotics aren’t usually needed. Tissue spears – a tissue end, rolled into a point, can be gently inserted to mop up discharge from a perforated OM or grommet-associated discharge.

There are some serious complication of OM;

Mastoiditis is a clinical, not radiological, diagnosis; only 53% of patients had a history of previous AOM. Contrast CT with bony windows or temporal bones is 97% sensitive for identifying complications, 3rd generation cephalosporins and flucloxacillin is the Sydney Children’s Hospital treatment and some cases do require surgery for abscess drainage.

Nasal fractures in children are usually minimal displaced or greenstick in kids under 6yrs of age; remember to check for a septal haematoma and ENT would generally like to review at 5-7 days as fractures are usually overdiagnosed due to oedema in the first 7 days. Imaging is not usually needed (though might have been performed for other reasons eg head trauma). Major septoplasty is usually reserved for older children.

Septal haematoma occurs in 0.8-1.% of nasal trauma and may develop days later. There’s a risk of abscess development with local spread; symptoms include nasal obstruction, pain and headache. It requires early intervention for drainage and to close the deadspace in order to avoid a long term saddle nasal deformity.

For nasal FB, often there is a history of unilateral rhinorrhoea. There is a risk of aspiration; button batteries and magnets are the items of the most concern. For deeper FBs, co-phenylcaine (with time allowed for it to work) is your friend as it provides analgesia and decongestant. Pass your instrument beyond the FB and pull towards you. Other techniques are listed here (and see Donovan’s tips from yesterday).

Epistaxis affects 64% of children by age 15. Most are self-resolving and anterior are more common than posterior. For acute bleeding, apply direct pressure, sitting upright with the head forward. Pressure should be on the soft part of the nose (not the nasal bones!) and there is no evidence for cold compresses. Sometimes co-phenylcaine on a cotton wool ball can help you identify the bleeding source and some older children may need packing but often for younger children packing isn’t usually needed. Antiseptic cream and/or vaseline can be helpful. Remember each squirt of co-phenylcaine has 5mg lignocaine and there will be some mucosal absorption – so be mindful of dosing. I’m not a big fan of cautery in the ED if it can be avoided, but she had some tips for doing this safely with silver nitrate. Warn patients that they may experience some itching as things heal and they should avoid irritating the healing tissues.

Special cases in epistaxis; adolescent male, unilateral – could this be juvenile nasal angiofibroma? Post-surgical eg turbinate reduction, adenoidectomy nay need postnasal pack or balloon tamponade. For hereditary haemorrhagic telangiectasia the bleeding list persists so repeated cautery/packing is best avoided.

5-10% of URTI can lead to acute sinusitis with a mean after of 3-6y. Complications occur in 1:12,000; pre-septal cellulitis (80-90% of complications, usually <5yrs), orbital or post-septal cellulitis, subperiosteal abscess, orbital abscess and then cavernous sinus thrombosis. There are some useful warning signs of spread;

Management is centred around source control, imaging, decongestants, nasal steroid and antibiotics.

Tonsillitis is also common, with admission only really needed for poor intake or OSA. Antibiotics are recommended for 2025y with hight rise for rheum fever, pre-existing rheumatic heart disease or Scarlet fever. Peritonsillar abscesses tend to occur in older children (peak 14-17y). CT isn’t needed if you can see it and you can aspirate or incise often under local (but GA may be needed for younger patients).

Post-tonsillectomy haemorrhage peaks at day 5-10, occurring in 1-5% of cases. NSAID use has probably increased since codeine stopped being used and this might contribute to increased bleeding rates. Management is resuscitation, bloods, group and hold, TXA. The patient can suck ice, gargle peroxide, apply adrenaline on a swab if compliant. For most patients, bleeding will just stop by itself. For ongoing bleeding, cautery or suture can be used (often after GA with RSI, as typically kids swallow lots of blood – so expect them to vomit bloody fluid too). Embolisation and/or ligation of the external carotid artery is rarely needed. Clotting disorders are sometimes diagnosed due to excessive post-tonsillectomy bleeding.

Retropharyngeal abscess occurs in <5yrs in 75% of cases, M>F, typically GAS infections. CT scan is the preferred imaging modality; airway management may be needed, landmarks may be displaced and we should avoid traumatising the posterior pharyngeal wall (AFOI might be considered).

Penetrating oropharyngeal trauma carries the potential for neurological and vascular injuries but many are self-resolving. Follow-up is important though – even if trivial. There’s a thorough review paper here.

For partial oropharyngeal obstruction, finger sweep can be unhelpful. We can use an ETT in the nose but sitting in the nasopharynx to deliver O2 just beyond or at the level of the soft palate, avoid paralysis if spontaneous bleeding, and avoid a crash tracheostomy. Attempting dislodgement in the ED works better with a straight blade as many of the tools we use to grab the FB are also straight (McGills forceps) and so you aren’t fighting the blade curve. Remember to check for a second FB (!) and assess for traumatic injury.

Noisy breathing in a child? Acute cases are usually croup, occasionally epiglottitis, and bacterial tracheitis. Chronic causes include laryngomalacia (presenting in the first few weeks, often worse when crying or feeding, or during sleep), vocal cord palsy/airway stenosis (which can be congenital or acquired), haemangioma (usually the first few months), tracheomalacia or vascular ring (usually worse when eating solids).

Bacterial tracheitis isn’t seen very often; it tends not to be seasonal (unlike croup) with peak incidence 3-8yrs (though it can affect 6m-14y). There is a thick, adherent tracheal exudate presenting with cough, stridor, hoarseness, fever and tachypnoea. This should prompt an urgent laryngobroncoscopy if the patient doesn’t respond to croup treatment, if there is biphasic stridor, if the child is tiring or if there is respiratory distress. Typical organisms are S.aureus, S.pneumoniae, M.catarrhalis and treatment includes exudate removal, antibiotics, steroids and sometimes intubation.

Inhaled foreign bodies may be unwitnessed and can be almost anything – children typically present with coughing and gagging, then stridor and dysphagia. Consider in new onset unilateral wheeze, variable respiratory distress, and don’t discount in the presence of fever (which can occur if presentation is delayed). Organic material is worse as it often provokes an additional inflammatory response.

Marlene ended with a reminder to be #ButtonBatteryAware. Honey can be used if the child is over 12m of age (due to botulism risk) and if it’s less than 12h since ingestion – 10ml every 10mins for up to 6 doses (this will reduce hydroxide formation). Don’t delay transfer for this – ENT will manage as a cat 1 emergency for removal in the case of a confirmed impacted button battery. There have been 3 paediatric deaths from button battery ingestion in Australia since 2013 – Australia is the first country in the world with mandatory standards around packaging and safety information regarding button and coin batteries.

Her conclusions:

Marie-Clare Elder – Extended Duty of Care

Marie-Clare Elder is a lawyer, who took us through some of the case law around third party claims surrounding psychiatric harm by virtue of being close to someone who has been injured. The elements of these claims usually include;

1. Physical proximity to a traumatic incident/accident
2. Relationship with the primary victim
3. That the plaintiff be a person of normal fortitude
4. That the plaintiff suffers from a recognised psychiatric illness

These sort of claims arise from this lawsuit from 1888, in which there was a near miss between a horse and carriage on a level crossing and a train; there was no physical harm or contact but afterwards one of the plaintiffs had a miscarriage following the stress and shock, and the couple sued claiming the miscarriage arose from the negligence of the railway. Since then, legal definitions have moved on to consider that an “illness of the mind set off by shock is not the less an injury because it is functional, not organic, and its process is psychogenic.”

Most recent case law in Australia supports claims by plaintiffs if there is a breach of duty of care to the deceased party even if they have not directly witnessed the death.

Three recent UK Supreme Court cases (1, 2 & 3) brought claims for damages for psychiatric injury as secondary victims. In each case, the medical practitioners have accepted breach of duty of care to the patients, however, the Supreme court has drawn a line and refuses to accept that responsibility of a medical practitioner “extend to protecting the members of the patient’s close family from exposure to the traumatic experience of witnessing the death or manifestation of disease or injury in their relative. To impose such a responsibility on hospitals and doctors would go beyond what, in the current state of our society, is reasonably regarded as the nature and scope of their role.” The implications of this judgement for legal practice in Australia are not yet tested.

So what are the considerations for us, in the EM/PEM and even PHARM space? If you have to make difficult calls or have a difficult interaction (including removal of parents from a resuscitation room), document the management of the family as part of the medical record. Document who was present and how those decisions were made (note: I document whomever is present in the cubicle with the patient for every single ED assessment and have done since I prepared a legal statement for a hospital court case early in my career). Avoid giving graphic details over the phone wherever possible. Ideally, document the content and subject matter of conversations you have with family members. Settlements are common; particularly where deaths are involved, there is a definite disinclination to air details and re-traumatise the plaintiffs in court. Consent for procedures should be individualised to then patient and their circumstances – and this is a very sticky area of medicolegal practice.

Remember, there does have a to be a breach of the duty of care for the patient for a claim to proceed (not just that the phonecall to inform them of their relative’s death upset them).

Craig Walker – Sodium Balance and Regulation

Choice of fluid therapy for paediatric patients has long been problematic – apparently for the average 5yr old with diarrhoea, the composition of the stool (and therefore the loss) is approximately half normal saline, so it would seem to make sense to replace losses with half normal saline.

Paediatricians are typically concerned about hypernatraemia and also about dehydration, often based on historical problems that don’t really play out in current medical practice. There is a definite range of fluids that paediatric patients can tolerate – a definite bell curve. In acute illness, that bell curve might become narrower, but then the disease process itself might displace the curve to the left or right.

There was a lot of physiology and biochemistry in this talk that I’m not sure I can do justice to, but his key points were:

1. Serum sodium is primarily a marker of your water state, not your sodium state.
2. The patient’s sodium state is reflected by their serum sodium.

SIADH is probably a misnomer; it is an evolutionarily appropriate response to acute stress (eg illness, injury) that helps us hold on to sodium and water. When we add fluids artificially, usually as IV therapy, we disrupt these processes and often the harm caused is in fact iatrogenic. When we talk about maintenance fluids, we should be asking ourselves “what are you trying to maintain?”

We are probably trying to maintain volume state (to prevent shock) and tonicity state; the former is related to sodium and the latter by water. These are determined by both type and AMOUNT of fluid. All patients are different. Many patients will survive despite what we do (so we are unlikely to find the answer from large RCTs). Hyponatraemia = water overload; volume state is a marker of sodium state. The gut is protective; rehydration using the gut is generally preferable (this might involve antiemetics and/or NGT in paediatric patients).

What does Craig to on PICU in hyponatraemia?

1. Give Na+ containing fluid if hypovolaemic
2. Restrict free water if hypervolaemia or euvolaemic.

I’m acutely aware that last time I didn’t quite get around to writing up my Day 3 notes, so I’ve put them here too.

John Pereira – Neuroradiology for the Non-Radiologist

CT advantages

• Readily available
• Fast (seconds-minutes)
• Less sensitive to patient motion
• Detailed evaluation of bone/haemorrhage
• Accurate detection of calcification/metal
• No risk with implantable medical devices

Disadvantages

• Ionising radiation
• Low soft tissue resolution
• Single plane acquisition

When we consider radiation exposure and its effects, we can think about these in two different categories.

Deterministic effects, for example skin burns, are predictable and reproducible. They occur immediately and usually only last for a short time, and their severity increases with the radiation dose. There is a minimal threshold before there is a noticeable effect.

In contrast, stochastic effects are caused by chance. There is no minimum threshold although risks are cumulative and increase with dose, with manifestations occurring after a latent period. Examples include cancer and genetic changes. These effects inform the way we think about dosing in radiology.

Radiation doses for common imaging modalities are shown below but these don’t make a lot of intuitive sense to us.

• One PA CXR = 30uSV
• One hour of plane flight = 3.24uSv
• Round trip SYD-USA = 100uSV
• One year environmental = 2.5mSv

So what are the advantages of MR imaging?

• No ionising radiaiton
• High soft tissue resolution eg brain
• Multiplanar
• Multisequence for different diagnoses
• MR contrast has lower risk of reactions
• Able to image around metallic/bone artefacts

Disadvantages

• Availability
• Cost
• Long examination time
• Not an option with some implantable devices

In T1 weighted images, white matter of the brain appears white.

In T2 weighted images, water containing areas appear white (eg CSF, eyeballs).

There are various nuances to the different MR modalities that can help to delineate abscess, DAI, cavernomas etc.

Much of the talk was highly imaged-based and doesn’t really translate well to written notes.

CT perfusion has three parameters: cerebral blood flow (CBF), cerebral blood volume (CBV) and mean transit time (MTT) or time to peak (TTP). Normal values exist, with greater flow in grey matter than white matter. The area of infarct has prolonged MTT with markedly decreased blood flow and volume, whereas the penumbra (the potentially salvageable area) will also have prolonged MTT but only moderately CBF but normal or near-normal CBV. These can help to delineate the amount of tissue that could be saved. Plenty of great stuff on this from our friends over at Radiopedia.

Derrick Tin – From Chaos to Calm: An Exploration of Disaster and Counter Terrorism Medicine

Conflict, terrorism and humanitarian crises often go hand-in-hand; we generally have frameworks for anticipating and managing the trauma-related implications of particular incidents, the multiple layers of man-made disasters (which are generally considered to be entirely preventable) can confound the normal workflows. 3000 people died in the immediate 9/11 events, something we might not have been able to impact from a medical perspective – but there were 18000 subsequent deaths that perhaps could have been prevented.

Cyberattacks are probably underestimated by healthcare professionals – evidence suggests they increase mortality rates.

Much of the rest of Derrick’s talk was interesting but focused on his experiences and his career with limited broader applicability to everyday practice. His work has involved researching and understanding incidents in order to better equip services and departments for managing patients in the aftermath. You might find his pre-COVID19 TedX talk interesting and prescient.

He did make am impassioned plea for better leadership and media training in our frontline practice; if something was to happen around or even in your facility, how personally prepared would you be to lead your facility response?

Hurricane Katrina in the US has prompted some closer work around the impact on children, with this 2010 report calling for the unique needs of children to be considered and integrated into disaster planning. Blast injury patterns, for example, are quite different between terrorist-related and non-terrorism related mechanisms of injury and also between adult and paediatric patients – this review covers this well.

Derrick also recommends this paper, to reflect on our readiness to care for paediatric patients in chemical and radiological events.

Those are all my notes, so until next time – stay safe and be awesome at what you do.

Nat