Premier Conference Day 1

Paediatric Emergency Medicine – Premier Conference – Day 1

Regular blog readers and podcast listeners will remember our content from the Premier (Paediatric Emergency Medicine) conference last year. It was great to be back at the Hope Church in Winchester again for a packed programme full of paediatric pearls of wisdom. In this post, I’ll give you some of the highlights from Day 1, but look out for a series of podcasts that will be out soon. Many thanks to my colleague Nicky Sparrow for helping me to put this post together. This is just the highlights from the morning session, with more to come over the next few days.

Stroke in Children – Jaspal Singh

This is obviously a hot topic at the moment, with more information available in Nat’s post from Noosa.

The top learning points were:

  • Stroke in children is rare, and intervention with either thrombolysis or thrombectomy is even rarer and very poorly evidence-based
  • About 400 children will have arterial ischaemic strokes per year in the UK
  • Considerably more stroke mimics in children; not all acute ischaemic stroke is treatable with thrombolysis or thrombectomy
  • Significant challenges: delays to diagnosis, imaging and its interpretation are challenging, wide range of risk factors, angiography in children rarely performed

ENT Pearls – Ellie Sproson

Ellie had some great pearls and this talk covered a wide range of common (and not so common) pathologies, across the E, N and T.

Ear

  • 70% of 2 year olds have glue ear – otitis media with effusion
  • Prolonged discharge often Pseudomonas otitis media – ciprofloxacin ear drops for 10 days
  • Otitis external – no indication for oral antibiotics, keep the ear dry and may need referral for micro suction

Nose

  • Press on the correct part of the nose in epistaxis – the ‘squashy part’ and advise a long course of bactroban ointment.
  • Mostly down to picking (even if children – and parents – deny it)
  • Nasal fractures – if it isn’t deviated, there is no need for further follow-up.

Throat

  • Quinsy – deviation of uvula not a good/ predictive sign
  • Airway emergencies – most common in children born prematurely, or if there has been any intubation as an infant.

Headaches in Children – Lucia Santos

These represent 1% of attendances in children’s emergency departments, and at the back of all parents’ minds is, “Could this be a brain tumour”. In emergency medicine, we are obsessed with ruling out the worst-case scenario, so this is likely to be at the front of our minds, too…

In truth, the majority are due to a viral illness, minor head injury, or sinus infection (up to 60%), with 20-30% having a primary headache.

Red flags
Acute onset of severe headache. 
Headache at night or on waking from sleep
Vomiting at night or on waking from sleep
Recent onset <6 months 
Steadily worsening pattern (frequency or intensity)
Worse when lying down or asleep or bending down, straining or coughing
Change of the character of headache in patients diagnosed with primary headache
Change in personality, behaviour, worsening schoolwork or lethargy
Increasing head circumference in children under 2 years of age.
Abnormal growth or puberty
New neurological signs 
High-risk populations: sickle cell anaemia, malignancy, recent head trauma, ventricular-peritoneal shunt.
Young age of onset
Neurocutaneous stigmata: café- au-lait macules, hypopigmented macules. 
Recent onset of seizures

The life-threatening illnesses are the stuff of emergency physician nightmares:

  • Brain tumour
  • Central nervous system infections
  • Ventriculoperitoneal shunt malfunction or infection
  • Venous sinus thrombosis
  • Ischaemic Stroke
  • Cervical artery dissection
  • CNS Haemorrhage
  • Coarctation of aorta
  • Carbon monoxide poisoning

Sudden Cardiac Death in the Young – Harshill Dhuttia

This is rather different to sudden arrhythmic death syndrome – where a cause can be found at post-mortem and represents the majority of cases.

Surprisingly, it is the leading cause of (non-traumatic) death in the young, with often no preceding illness or presentation, with cardiac arrest being the first presentation in 85%. You need to have a high index of suspicion in any patient with syncope, particularly if there is an association with exercise or injury.

Although these conditions are not curable, their potential harms can be minimised with treatment, such as beta blockers and, in some cases, implantable cardiac defibrillators (but the potential benefit must outweigh the harm).

Maintenance and Reliever Therapy in Asthma – MART – Steph Harper

  • MART = Maintenance And Reliever Therapy
  • Asthma in top 10 conditions requiring admission
  • Drugs – budesonide + formoterol (quick acting LABA) – ie Symbicort
  • 39% reduction in severe exacerbations using a MART regime
  • Fostair is not recommended in children.
  • Age 6+ can use a dry powder inhaler
  • Discharge plans
  • Dry powder devices are not suitable for children with anaphylaxis to Milk – as advised by our allergy team. These patients can use MDI
  • Inhaler technique must be checked
  • Wessex Asthma Network guidelines published
  • Salbutamol should not be the inhaler to discharge!!

Vaping in Children – Helen Stewart

As the father of two teenagers, the numbers Helen shared about the use of vapes amongst the young were alarming.

Data is from ASH England (Action on Smoking and Health), shows that 20.5% of 11-17-year-olds have tried vaping at some point, up from 15.7% in 2022. Bear in mind this is across the whole 11-17 age group. When broken down by age, the higher proportion is from the older age bracket. E-cigarettes are sold as a smoking cessation tool, but 11.5% of young people who have never tried a cigarette have tried vaping.

Put another way, nearly 50% of children who have tried vaping have never smoked. Young non-smokers who use vapes are more likely to take up smoking than non-users. There is emerging evidence that e-cigarette use in children can lead to cigarette use, acting as a gateway.

It’s difficult to talk about medical harm regarding vapes. There isn’t a lot of evidence. It took many decades it took to fully understand the harm caused by cigarettes; it’s still very early days. But more and more is emerging.

There are documented cases of vaping-associated lung injury, with a large outbreak in the US in 2019 that may have been responsible for several deaths and 2 lung transplants. E-liquid aerosols are linked to direct harm to respiratory epithelium, reduced pulmonary function, inflammation and altered mucociliary clearance. NHSE data shows 40 admissions that may be linked to vaping.

And it could exacerbate health inequalities. Socioeconomic deprivation has been linked with vaping among non-smokers. These are people already at risk as they are more likely to live in poor housing and have higher pollution levels, both of which can impact respiratory health and mental health problems, which are also linked to an increase in the risk of vaping.

The Royal College of Paediatrics and Child Health is proposing tough new action on the use of vapes in young people, including a ban on disposable e-cigarette products – these are disproportionately used by young people and have huge environmental harm. Rechargeable ones will still be available for those who are using them to stop smoking, but there is no real need for there to be a disposable version. A ban can be achieved quickly under environmental legislation and could also make identifying those brought into the country on the black market easier to identify as they are currently hard to tell apart.

The current loophole on children being given free samples needs to be closed, and the flavours that might appeal specifically to the young discontinued – rainbow unicorn flavours not necessary, with advertising limited to vaping as a smoking cessation device and not a lifestyle product.

Conclusion

This was just the first two sessions of a packed first day – there is much more to come. Look out for podcasts recorded at the conference and be sure to follow @PremierWessex for updates and news about events in the future.

Podcasts from Premier 2023

Cite this article as: Iain Beardsell, "Paediatric Emergency Medicine – Premier Conference – Day 1," in St.Emlyn's, June 11, 2024, https://www.stemlynsblog.org/paediatric-emergency-medicine-premier-conference-day-1/.

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