Things We Like This Month – October 2019

As the temperatures begin to fall and the children slink off back to school, the keen-eared paediatrician will likely hear the faint sound of wheezing drifting over the horizon…

Winter is here again, folks, and has well and truly landed in Norwich. So as you jog between salbutamol laced patients, NG tubes at the ready for the second wave of bronchiolitic patients, why not take a short break from the ward, sit down with some tea, and have a little look at the Things We Liked This Month – our little round up of all things #FOAMped this month.

Journal Articles we like

Fifteen Minute Consultation: How to be the paediatrician at a trauma call

As a general paediatrician, the trauma call is not something that falls in the scope of our usual day-to-day practice. The Major Trauma Network has revolutionised trauma care in the country, but one of the downsides of seeing less trauma in a DGH is that teams become deskilled, and unused to running a slick and effective trauma call for when the inevitable trauma comes into ED. This article is part of the “Fifteen Minute Consultation” series that we not-so-secretly love here at Norwich PEM, and puts you in the shoes of the paediatric team at a trauma call, with the task of assessing and managing circulation. As there are key differences to managing the circulation of a critically injured and critically unwell child, safely and effectively managing this system will allow you to not only survive, but thrive in a resuscitation scenario that we are not faced with often.

Use of CT in children with minor head injuries with isolated vomiting

Children fall over. A lot. And this is a constant source of worry to parents and family, often showing up to ED at all times with questions about head injuries. Luckily for us, the vast, vast majority of children with head injuries are absolutely fine, and need nothing more that some advice and calming words of reassurance to the parents. For those with more significant symptoms, there are a slew of clinical tools to aid us to the decision as to who requires a CT scan and who doesn’t. In the UK, the NICE Head Injury guideline dominates, and is based of a 2006 paper in the ADC widely referred to as the CHALICE study. This guideline clearly states which children require CT scans within an hour, those that should be observed, and those that can be safely discharged. Often one of the more contentious points is the assertion that children with “three or more discrete episodes of vomiting” should be observed, and should they have any further vomiting, should have a CT scan. This is one of the more common reasons for children who appear well to get a CT scan, as well as one of the more common areas where experienced clinicians will deviate from the guideline. There have been a few papers in recent years looking at whether isolated vomiting post head-injury carries an greatly increased risk of clinically important TBI (ciTBI), and this systematic review is the latest addition to that. It backs up the work of the more recent (and perhaps more valid…) PECARN decision rule, that in isolated vomiting of >3 episodes, close clinical observation is justifiable, with a ciTBI rate of 0.2-0.3%. Interestingly, isolated vomiting in adults has a higher rate of ciTBI, and therefore potentially should be considered more relevant in older children and adolescents.

In all cases, clinical decision tools are there to aid the clinician, rather than dictate their next move, however, this review adds weight to the argument for clinical observation in isolated vomiting rather than strict adherence to the NICE guideline.

#FOAMed content we like

Seat Belt Injuries – Don’t Forget the Bubbles

Assessing children who have been involved in road traffic collisions is an important part of what we do in the ED. Children have a phenomenal physiological reserve and can look relatively well despite significant injuries which is why careful assessment of these patients is essential. This article shows you an important clinical sign and covers what you should worry about and how to appropriately investigate children who have it – its a must read for all of us.

Purple Crying

I was, until recently, completely unaware of this website, and I wish I had known about it sooner. Children crying and in distress is a cause of a lot of concern, especially to new parents. Expert paediatricians in development have noted that there is an increase in crying intensity, frequency and length from about 2 weeks to up to 3-4 months. This is normal, although distressing for parents. Often, as clinicians, we are asked to seperate what is normal from what is abnormal, and this is especially important in the first few weeks of life. “Is it normal for them to cry like this?” is a question bounced around GP surgeries, A&Es, CAUs and new patient clinics across the country, and having a resource that explains to parents that this is normal, expected, everyone goes through it, and tips on how to deal with it is a fantastic safety netting resource.

Podcasts we like

Industry Influence in Paediatrics – The DFTB Podcast

Although not as clinically based as the usual podcasts I find myself listening to, this new venture from the folks at DFTB was an absolutely fascinating listen. In it, Chris van Tulleken talks about the influence that pharmaceutical companies, in particular milk formula companies have on our practice. With new legislation in place to minimise their outward influences, the days in which lavish dinners and conference spots, all paid for from pharmaceutical coffers, would be thrown at doctors are largely gone. However, to assume that this was the end of pharma influences would be naive at best. A particular highlight was the revelation that, whilst most of us as clinicians believe that others can be easily influenced by companies, very few of us believe that we are influenced ourselves. Chris breaks down the subtle forces of influence from pharmaceutical companies, be they pressuring guideline reform, funding charities, and disseminating information via patient-facing websites, all for the promotion of their product. That there is an influence from companies in healthcare is not a surprise to anyone, but the amount of self reflection that this podcast prompted in me was staggering. Where am I being influenced? And am I passing that influence onto my patients unknowingly? It is difficult to rid ourselves completely of the grasps of these pressures, but having an awareness of how, where and why these companies operate and put pressure on medical opinion is extremely enlightening, and key to reducing the overall influence these companies have.

Intraosseous Devices – Paediatric Emergency Playbook

This podcast is an excellent guide to insertion of an IO needle for those who are new to it and a solid refresher for the rest of us who, lets face it, aren’t doing them all that often. It also covers some of the less commonly discussed aspects of intraosseous access including what you can and can’t test the aspirate for and using it to administer IV contrast – questions which will undoubtedly come in handy when you’re in a bind at 4am.