PEMLit Review at #IAEM2015 in Cork

Editor's Notes

1. Clinician Suspicion or Prediction Rule for Blunt Abdominal Trauma? Academic Emergency Medicine PECARN group The big question: are clinicians better at predicting intra-abdominal injuries in children with blunt torso trauma than a derived clinical prediction rule. Secondary analysis of some existing PECARN group data from a prospective cohort study of children with blunt torso trauma. Low risk (<1%) clinician suspicion had the following test characteristics; sensitivity 82.8% (95% CI 77.0-87.3), specificity 78.7% (95% CI 77.9-79.4%), NPV 99.6 (95% CI 99.5-99.7%), LR- 0.2 (95% CI 0.2-0.3).
2. Clinician Suspicion or Prediction Rule for Blunt Abdominal Trauma? Academic Emergency Medicine PECARN group The big question: are clinicians better at predicting intra-abdominal injuries in children with blunt torso trauma than a derived clinical prediction rule. Secondary analysis of some existing PECARN group data from a prospective cohort study of children with blunt torso trauma. Low risk (<1%) clinician suspicion had the following test characteristics; sensitivity 82.8% (95% CI 77.0-87.3), specificity 78.7% (95% CI 77.9-79.4%), NPV 99.6 (95% CI 99.5-99.7%), LR- 0.2 (95% CI 0.2-0.3).
3. Repeated ED Visits in Children With Meningitis/Septicaemia - Annals of Emergency Medicine June How often have children, subsequently diagnosed with meningitis or septicaemia, attended an ED and been discharged in the preceding five days? Retrospective cohort study identifying children (aged 30 days to 5 years) with a diagnosis of meningitis or septicaemia and linking their data to a database to determine preceding ED attendances in the five days before their admission visit. 521 children were admitted with an ultimate discharge of meningitis or septicaemia of whom 125 had attended an ED in the preceding 5 days. Reassuringly those with repeated visits had similar lengths of stay, critical care use and 30-day mortality. Safety netting matters! Meningitis/septicaemia may not be immediately apparent so it’s important that parents feel comfortable bringing children back to the ED if they have concerns. This is something that plays out in popular media too.
4. Repeated ED Visits in Children With Meningitis/Septicaemia - Annals of Emergency Medicine June How often have children, subsequently diagnosed with meningitis or septicaemia, attended an ED and been discharged in the preceding five days? Retrospective cohort study identifying children (aged 30 days to 5 years) with a diagnosis of meningitis or septicaemia and linking their data to a database to determine preceding ED attendances in the five days before their admission visit. 521 children were admitted with an ultimate discharge of meningitis or septicaemia of whom 125 had attended an ED in the preceding 5 days. Reassuringly those with repeated visits had similar lengths of stay, critical care use and 30-day mortality. Safety netting matters! Meningitis/septicaemia may not be immediately apparent so it’s important that parents feel comfortable bringing children back to the ED if they have concerns. This is something that plays out in popular media too.
5. Afebrile Infants Investigated for Serious Bacterial Infection in the ED - Paediatric Critical Care The big question: do infants investigated for serious bacterial infection (SBI) without a history of fever have SBI? What did they do? A retrospective analytical observational study of infants aged 0 to 60 days presenting to the ED for reasons other than fever who were investigated for SBI (defined as two or more of: urinary culture, blood culture, CSF culture). Rates of SBI were compared with patients presenting in the same age range in the same period with fever. What did they find? 362 patietns in the fever group and 217 patients in the afebrile group met inclusion criteria. Positive blood cultures with true pathogens were found in 10 febrile patients (2.8%) and 2 afebrile patients (0.9%). Positive urine cultures were found in 10 (2.7%) of the febrile group and 4 (1.8%) afebrile patients. All cases of bacterial meningitis were in the febrile group. Overall, of all patients investigated for SBI, 5 in the afebrile group (2.3%) and 20 of the febrile group (5.5%) had a documented SBI. What does this mean? SBI can present in infants in all sorts of ways and not necessarily with fever. Have a low threshold for SBI workup infants behaving strangely/badly in the ED.
6. The big question: do infants investigated for serious bacterial infection (SBI) without a history of fever have SBI? What did they do? A retrospective analytical observational study of infants aged 0 to 60 days presenting to the ED for reasons other than fever who were investigated for SBI (defined as two or more of: urinary culture, blood culture, CSF culture). Rates of SBI were compared with patients presenting in the same age range in the same period with fever. What did they find? 362 patietns in the fever group and 217 patients in the afebrile group met inclusion criteria. Positive blood cultures with true pathogens were found in 10 febrile patients (2.8%) and 2 afebrile patients (0.9%). Positive urine cultures were found in 10 (2.7%) of the febrile group and 4 (1.8%) afebrile patients. All cases of bacterial meningitis were in the febrile group. Overall, of all patients investigated for SBI, 5 in the afebrile group (2.3%) and 20 of the febrile group (5.5%) had a documented SBI. What does this mean? SBI can present in infants in all sorts of ways and not necessarily with fever. Have a low threshold for SBI workup infants behaving strangely/badly in the ED.
7. THAPCA-OH - NEJM The big question: does therapeutic hypothermia improve confer a survival benefit in children with out of hospital cardiac arrest? What did they do? single-blinded, multicentre randomised controlled trial in which children with ROSC were randomised one-to-one to therapeutic hypothermia for 48h then normothermia for 72h, or active normothermia for 120h. The outcome of interest was survival at 12 months with good neurological function (defined as age-corrected standard score of 70 or more on the Vineland Adaptive Behaviour Scales (VABS-II) What did they find?  295 patients were randomised:155 were randomised to hypothermia, 140 to normothermia. Survivors at 12 months with VABS-II score >70 - Hypothermia 27/138 (20%), Normothermia 15/122 (12%) Risk difference 7.3 (95% confidence interval -1.5 to 16.1) Relative likelihood 1.54 (95% confidence interval 0.86 to 2.76, P=0.14) What does this mean? Insufficient evidence to reject the null hypothesis of no difference between groups but clinically a big difference – would be justified in arguing for continuing to provide therapeutic hypothermia I think.
8. THAPCA-OH The big question: does therapeutic hypothermia improve confer a survival benefit in children with out of hospital cardiac arrest? What did they do? single-blinded, multicentre randomised controlled trial in which children with ROSC were randomised one-to-one to therapeutic hypothermia for 48h then normothermia for 72h, or active normothermia for 120h. The outcome of interest was survival at 12 months with good neurological function (defined as age-corrected standard score of 70 or more on the Vineland Adaptive Behaviour Scales (VABS-II) What did they find?  295 patients were randomised:155 were randomised to hypothermia, 140 to normothermia. Survivors at 12 months with VABS-II score >70 - Hypothermia 27/138 (20%), Normothermia 15/122 (12%) Risk difference 7.3 (95% confidence interval -1.5 to 16.1) Relative likelihood 1.54 (95% confidence interval 0.86 to 2.76, P=0.14) What does this mean? Insufficient evidence to reject the null hypothesis of no difference between groups but clinically a big difference – would be justified in arguing for continuing to provide therapeutic hypothermia I think.
9. S100B for identifying intracranial injury in children with mild head trauma - EMJ September The big question: can S100B rule in/rule out intracranial injury in children with mild head trauma? What did they do? Prospective cohort of consecutive patients under 16 presenting to one of three Swiss paediatric EDs with mild head injury (acute head trauma with confusion or LOC <30mins or amnesia or transient neurological abnormality) for whom a CT was requested; these subjects also had a venous blood sample for S100B level which was not available before CTs had been reported. They then determined test characteristics for S100B in the context of CT findings. The sample size was pretty small – 80 children were enrolled. What did they find? Only 73/80 were included in the analysis, of whom 20 had an intracranial injury. No surgical interventions were required in any case. The ROC curve for S100B had an AUC of 0.73 (95% CI 0.60-0.86) which improved to 0.77 (95% CI 0.65-0.89) when under 2s were excluded. Using a cutoff of 0.14micrograms/L gave a sensitivity of 95% (95% CI 77%-100%) for all children (100% (95% CI 81%-100%) with under 2s excluded) and specificity 34.0% (95% CI 27%-36%). What does this mean? We can’t yet use S100B to exclude intracranial injury in children with “mild” head injury but there is potential there following further studies in larger populations and with a priori analyses excluding under 2s.
10. S100B for identifying intracranial injury in children with mild head trauma - EMJ September The big question: can S100B rule in/rule out intracranial injury in children with mild head trauma? What did they do? Prospective cohort of consecutive patients under 16 presenting to one of three Swiss paediatric EDs with mild head injury (acute head trauma with confusion or LOC <30mins or amnesia or transient neurological abnormality) for whom a CT was requested; these subjects also had a venous blood sample for S100B level which was not available before CTs had been reported. They then determined test characteristics for S100B in the context of CT findings. The sample size was pretty small – 80 children were enrolled. What did they find? Only 73/80 were included in the analysis, of whom 20 had an intracranial injury. No surgical interventions were required in any case. The ROC curve for S100B had an AUC of 0.73 (95% CI 0.60-0.86) which improved to 0.77 (95% CI 0.65-0.89) when under 2s were excluded. Using a cutoff of 0.14micrograms/L gave a sensitivity of 95% (95% CI 77%-100%) for all children (100% (95% CI 81%-100%) with under 2s excluded) and specificity 34.0% (95% CI 27%-36%). What does this mean? We can’t yet use S100B to exclude intracranial injury in children with “mild” head injury but there is potential there following further studies in larger populations and with a priori analyses excluding under 2s.
11. Oxygen saturation targets in infants with bronchiolitis - the Lancet September The big question: is target oxygen saturation of 90% or higher equivalent to 94% or higher for resolution of illness in acute viral bronchiolitis? What did they do? Parallel group, randomised controlled equivalence trial at 8 centres across two x 6-month winter bronchiolitis seasons. Infants aged 6 weeks to 12 months who presented acutely with clinically diagnosed bronchiolitis and required admission randomised to standard sats monitoring or a modified monitor with skewed readings such that SpO2 90% read as 94%. Standard care therein; primary outcome measure was time to resolution of cough (as a proxy for resolution of illness) What did they find? 308 randomised to standard care, 307 to modified care. Equivalence found in primary outcome – no difference in median time to cough resolution. The modified group also had quicker return to adequate feeding and “back to normal” time. Patients in the modified group, predictably, received supplemental oxygen in fewer cases, for a shorter period, were considered fit for discharge sooner and were discharged sooner. There were fewer serious adverse events and adverse events in the modified group. The modified group had increased HDU admissions but fewer reattendances What does that mean? Time taken for symptom resolution was equivalent whether target SpO2 was 94% or 90% however this was an inpatient population for whom a need for admission had already been identified. The fact that the modified group were discharged more quickly might suggest that there are harms caused by the administration of oxygen (drying of nasal passages, impacting on feeding) but for us in the ED it is difficult to know how to put this into practice. Further work to be done here.
12. Oxygen saturation targets in infants with bronchiolitis - the Lancet September The big question: is target oxygen saturation of 90% or higher equivalent to 94% or higher for resolution of illness in acute viral bronchiolitis? What did they do? Parallel group, randomised controlled equivalence trial at 8 centres across two x 6-month winter bronchiolitis seasons. Infants aged 6 weeks to 12 months who presented acutely with clinically diagnosed bronchiolitis and required admission randomised to standard sats monitoring or a modified monitor with skewed readings such that SpO2 90% read as 94%. Standard care therein; primary outcome measure was time to resolution of cough (as a proxy for resolution of illness) What did they find? 308 randomised to standard care, 307 to modified care. Equivalence found in primary outcome – no difference in median time to cough resolution. The modified group also had quicker return to adequate feeding and “back to normal” time. Patients in the modified group, predictably, received supplemental oxygen in fewer cases, for a shorter period, were considered fit for discharge sooner and were discharged sooner. There were fewer serious adverse events and adverse events in the modified group. The modified group had increased HDU admissions but fewer reattendances What does that mean? Time taken for symptom resolution was equivalent whether target SpO2 was 94% or 90% however this was an inpatient population for whom a need for admission had already been identified. The fact that the modified group were discharged more quickly might suggest that there are harms caused by the administration of oxygen (drying of nasal passages, impacting on feeding) but for us in the ED it is difficult to know how to put this into practice. Further work to be done here.
13. Nursery Songs to Reduce Anxiety in Infants and Young Children Undergoing Head CT - American Journal of Emergency Medicine The big question: does playing nursery songs plus a human heartbeat reduce anxiety scores in children and infants undergoing head CT? Randomised a small prospective cohort of children requiring CT scan to hear children’s nursery rhymes and a human heart beat (synchronized) for three songs prior to CT. Initial agitation scores were similar before the intervention; the experimental group had 53% decreased in anxiety scores during the CT compared with 25% of the control group. This is a pretty difficult study to develop a robust methodology for and there are lots of weaknesses BUT at the end of the day, there’s some evidence that music might be helpful in calming kids to facilitate CT scan. It’s cheap, it’s harmless – it’s worth a try :-)
14. Nursery Songs to Reduce Anxiety in Infants and Young Children Undergoing Head CT - American Journal of Emergency Medicine The big question: does playing nursery songs plus a human heartbeat reduce anxiety scores in children and infants undergoing head CT? Randomised a small prospective cohort of children requiring CT scan to hear children’s nursery rhymes and a human heart beat (synchronized) for three songs prior to CT. Initial agitation scores were similar before the intervention; the experimental group had 53% decreased in anxiety scores during the CT compared with 25% of the control group. This is a pretty difficult study to develop a robust methodology for and there are lots of weaknesses BUT at the end of the day, there’s some evidence that music might be helpful in calming kids to facilitate CT scan. It’s cheap, it’s harmless – it’s worth a try :-)