It’s an absolute delight to be at the PREMIER Wessex, Paediatric Emergency Medicine, Conference in Winchester. The Conference organisers have very kindly allowed us to record all of the audio and release it as St Emlyn’s podcasts in the future, but I thought I would try to give you some of the highlights to whet your appetite…
Introduction
PREMIER Wessex is part of the PIER Network (Paediatric Innovation Education and Research). For those of you not familiar with PIER it describes itself as ‘a collaboration of multidisciplinary health professionals working to improve the care of children and young people in the South of England through development of regional guidance, delivery of educational initiatives and exciting paediatric research’. In short it is run by an group of incredibly dedicated and passionate paediatric clinicians. They publish pragmatic and practical guidelines as well as organising lots of educational events.
Clarissa Chase introduced the conference as a ‘head to toe’ exploration of Paediatric Emergency Medicine and Trauma. All of the talks are deliberately short, and the speakers have been challenged to include only the most salient learning points.
The Venue
The conference is taking place at Hope Church, which I must admit is unlike any Church I have ever been to before. A converted Bingo Hall and Cinema in the middle of Winchester with conference facilities equivalent to any major venue. Special mention for ‘Andy the Sound Man’ who has helped us record all of the talks for podcast release. It is also the first conference I have been to with an ‘Artist in Residence’.
Day 1 – Paediatric Medical Emergencies
Session 1 – The Cranium
Talk 1 – Managing Non-Epileptic Events in the ED – Steve Warriner
A challenging, and common, event in the Emergency Department. 10% of attendances at paediatric neurology clinics are thought to be ‘functional’ and a lot of these will also present to the ED. These problems can involve a wide range of physical or sensory manifestations, almost all of wide have significant differential which we cannot miss.
A large number of these patients can end up with an incorrect diagnosis, some of this due to confirmation bias by clinicians, but also some with psychogenic non-epileptiform seizures may coexist with organic problems.
The history is key and can be helped significantly by watching videos of events. There may be other factors giving a clue to a non epileptic cause. Sometimes this will only happen in one place, like school, and the history may be inconsistent. Awareness and generalised bilateral movements, with episodes that are different each time all point to a non epileptiform origin. And then there are symptoms just ‘not fitting’ with our knowledge of dermatomal distribution.
There are Red Flags – Events happening during exercise, neurological signs, unpredictability and patterns to the events all point to a more sinister diagnosis
Management is incredibly difficult, particularly in trhe ED. Don’t suggest an organic diagnosis and leave some ambiguity. There is time to get more information and there are few definitive diagnostic tests. EEGs are notoriously unreliable. Self help groups can help.
Talk 2 – Brief Resolved Unexplained Events (BRUE) – Jillian Boden
The clue to these is very much in the Title – BRUE is a diagnosis in itself. Children often do weird stuff, but they rarely do weird scary stuff.
Over the last few years we have changed from ALTE – Apparent Life Threatening Events – to BRUE and this paper was key in this
BRUE occur in children under 12 months and last under one minute (usually less than 30 seconds). It has a sudden onset, with a return to baseline and not explained by identifiable medical conditions. Each episode must include one or more of the following:
- cyanosis or pallor
- marked change in tone (increase or decrease)
- altered, absent or abnormal breathing
- altered level of consciousness
Low-risk BRUE do not need extensive investigation or admission for observation. But how do we classify low risk? Age >60 days; Born >32 weeks; 1st episode and no CPR given by a medically trained professional
If your patient is ‘high risk’ (ie does not fit the low-risk criteria) then some investigations may be prudent: ECG to assess QT interval; NPA for pertussis, check for inborn errors of metabolism – blood glucose, bicarbonate and lactate; and other blood tests if clinically indicated (FBC/U&E/CRP).
The PIER network Guideline is here
Talk 3 – Managing prolonged seizures & waking in the ED – Ahmed Osman
Ahmed took us through a case of a two-year-old with prolonged fitting.
What could go wrong?
- Hypoventilation post benzodiazepines
- Failure to identify and treat the cause
- Failure to recognise ongoing seizure activity
Why don’t some seizures stop?
There may be dynamic neuroreceptor changes that perpetuate seizure activity – there is a reduction in functional GABA receptors and an increase in excitatory glutamate receptors
There is change afoot…
Ahmed hinted at a forthcoming change to the APLS guideline (mainly because he wrote it) and it may very well resemble the SORT guideline
There is a handy ABCD starting point, which should likely lead to intubation and ventilation
A: Airway obstruction requiring a jaw thrust, airway adjunct or the application of PEEP
B: Respiratory failure
C: Shock
D: Signs or symptoms of raised intracranial pressure, trauma, encephalopathy or focal neurology
Session 2- The Thorax
Talk 4 – Practicalities of SVT Management – Joe Schrieber
Supra ventricular tachycardias happen when the usual electrical activity of the heart is disrupted – usually via an accessory pathway or within the AV node itself.
Adenosine has often been our go-to to try to cardiovert, but this can come with some unpleasant side effects. Is there a better way?
Jo went on to talk about the REVERT study, which we have covered at St Emlyn’s before. The modified valsalva causes an increase in intrathorcic pressure and a subsequent drop in pre load. When this pressure is released it causes a sudden drop in BP which stimulates the atrial stretch and vagal response. The lifting of the legs increases the effect on preload and increases the chance of success
But will this also work in children? (the original trial was in adults). There is no reason to think that it won’t and some small trials have started to be done. It has started to make it into guidelines and is worth a go.
Talk 5 – Weaning ourselves off weaning plans – David James
There is very little evidence behind any of the weaning plans that we are so familiar with. Most of them were ‘made up’ and based on common sense rather than any scientific rigour. But if it ain’t broke do we need to fix it?
New guidelines have empowered parents to decide if their child needs bronchodilator, not just giving it just ‘because’.
Talk 6 – Anaphylaxis update – Nick Sargant
You can find a St Emlyn’s post on the new Anaphylaxis Guideline here
Children and adults do not present in the same way – children rarely have cardiovascular symptoms, many will no have dermatological manifestations and most have respiratory involvement. Co factors are also important – tiredness can worsen the anaphylaxis. Death remains rare – you are more likely to die being struck by lightning. Allergy and asthma also are closely associated.
Nick went through the guideline and accentuated the use of early adrenaline, the benefit of a fluid bolus and the lack of evidence for antihistamines (which are no longer in the guideline for anaphylaxis but may be useful to reduce the symptoms further down the line|). Steroids are also no longer recommended, and there is even evidence that the giving of steroids may independently increase the risk of ITU admission.
Biphasic reactions are uncommon, and risk factors include a more severe first presentation, requiring more than one dose of adrenaline, but this is an ‘evidence-free zone’.
Perhaps for those of us in the ED the most impactful section is about accelerated discharge.
Please do read this blog post about Max’s story
Session 3 – The Abdomen
Talk 7 – Management of Sexual Assault – Michelle Cutland
It is estimated that half a million children a year are sexually harmed in the UK every year. Many of these remain hidden but some will attend the ED
Immediate medical need – this may be the more ‘obvious’ presentation: strangulation; genital injury, seeking contraception, but there are lots of more subtle presentations, particularly in relation to psychological health.
Perhaps the primary role is to make the child feel safe. This will include establishing trust and being honest. You need to enable the child to have choice and control, even if it is only for a small thing within the whole presentation. Respond to the individual – SOPs are all well and good, but some children will want to be seen in the busy department and not put in a side room.
First impressions matter – your immediate reaction to the disclosure can have a significant effect on their subsequent recovery. Work hard to get this part right. Be profound in the moment (Candice Harris). Be mindful not to re-traumatise – you can ask for clarification but try not to make them relive the experience again. This could also include making sure you both know what you mean. Ask open questions, encouraging the child to tell the story in their own words.
Forensic sampling is best done as close to the assault as possible, although there can still be worthwhile findings several days afterwards.
Medical needs matter above everything – do what you normally do. Address what you can with regard to emergency contraception and PREP. Wear double gloves – this prevents you from inadvertently transferring your DNA onto the patient.
If in doubt get help – there are sexual assault referral centres across the UK
Talk 8 – Paediatric and Adolescent Gynaecology in the ED – Henny Lukman
The pregnancy test is the key to all of these consultations. The two key diagnoses are adnexal torsion and ectopic pregnancy
Ectopic pregnancy
3 deaths per year in the UK, 1 in 80 pregnancies are ectopic, that’s about 12,000 cases of ectopic pregnancy per year. Most of these (90%) are tubal. rum BHCG helps establish pregnancy, but doesn’t really help with where it is occurring.
Risk factors include: previous ectopic; IVF pregnancy; pelvic inflammatory disease and previous appendicitis. Atypical presentations are common, be particularly thoughtful with GI symptoms. Cervical excitation is a means of exhibiting peritonism from below.
Adnexal torsion
These are hard to diagnose and imaging tests are unreliable.
Talk 9 – Approach to the Metabolic Child in the ED – James Nurse
Think metabolic!
These patients are often picked up as part of newborn screening, but they can also present late. Families may be expert parents but don’t assume. These children can also present with ‘normal’ conditions.
Sometimes these patients will present at times of metabolic stress, from weaning through to pregnancy. Ask about other lifestyle changes – even starting to go to the gym in the teenage years may cause issues.
Try to resist the temptation to repeatedly ask the parents if they are related, but bear in mind that there are some groups that have a higher carrier frequency (the Irish Traveller population has a carrier rate of 1 in 11 for galactosemia).
Make it easy: if you suspect a metabolic disorder – stop feeds, give sugar and call a specialist.
If you need further information the British Inherited Metabolic Disease Group has excellent emergency guidelines
Spotlight session
This session had presentations on secondary trauma transfer, point of care ultrasound and management of the child under three months with fever.
Summary
I’m actually really surprised about just how nice it is to be in a room with colleagues at a conference again. After some reports to the contrary I can confirm that the face to face medical conference is not dead!
I am really grateful to the PREMIER team for making St Emlyn’s so welcome and I’m looking forward to bringing you more podcasts and content from the conference.
