Cast related harm
You have just seen Amelia, a 3year old girl who has represented after being seen in the department 3days ago when she was diagnosed with a toddler’s fracture. She was placed in a below knee backslab and discharged with fracture clinic follow up.
Her parents report that over the last 48hours she has started to complain of pain to her heel on that side and is becoming increasingly distressed by this.
Painful procedures in the ED
Painful procedures in the emergency department are often a source of anxiety for children, parents and even emergency medicine practitioners.
Abdominal pain in testicular torsion
You have just seen Leo, a 13year old boy who presents with an acute onset of RIF pain. You think that he has appendicitis and present the case to your consultant who asks “did you examine his scrotum?” You wonder, does every teenage boy presenting with abdominal pain really need a scrotal exam?
Rashes that affect the palms and soles
Whilst many rashes involve the dorsum of the hands and feet, very few involve the palms and soles.
Here are 6 conditions to think about in the patient presenting with a rash involving the palm and/or sole.
Fractures of the bones of the hand account for 10% of all fractures. In children, the majority of these are phalangeal fractures.
It is important to recognise that even minor, minimally displaced phalangeal or metacarpal fractures can cause significant functional impairment if they lead to overlap of the fingers when attempting to grip. This is otherwise known as a rotational deformity.
Magnet ingestions have a high risk of requiring surgical intervention.
Identifying hypertension in children
We know how to spot hypotension in children but what about hypertension?
Reducing procedural pain in infants
This video from the 'Be Sweet to Babies' research team at CHEO in Ottawa, Canada, demonstrates 3 techniques that have been shown to be effective in reducing procedural pain in infants.
Hair tourniquet is a relatively rare phenomenon which seems to affect the toes of infants in the majority of cases. It can however be found in older populations and can be found on fingers and genitalia.
Please see the attached QCH guideline for constipation – the main thing I have noticed working in paeds ED is that often children don’t receive high enough doses of laxatives, and they aren’t continued for long enough.
Merry Christmas everyone, and a great big thank you to everyone working over the festive period (I'm sure that's probably most of you!).
A little pre-Christmas pearl, a link to a paper demonstrating how dedicated paediatric EDs help improve patient waiting times and disposition.
Chest x-ray in pneumonia
In 2011 the British Thoracic Society published an update to their guideline on the management of community acquired pneumonia in children. This concluded that a chest x-ray should not be considered a routine investigation and that children with clinical findings suggestive of pneumonia, who are well enough to be managed as an outpatient, did not require imaging.
This practice has since been adopted across Australia and is replicated in our local guidelines.
A brief refresher on tetanus
Attached is a document that discusses the classification of wounds, determining immunisation status and links to guidelines that are used within Queensland Health to decide upon whether tetanus prophylaxis is required.
Mastering the art of distraction
There are a lot of tricks that need to be learnt when caring for the sick or injured child. Children are often fearful and distressed for a number of reasons when they are in hospital. It could be that they are experiencing pain, or that they are fearful of strange people that are lifting up their top to assess their work of breathing, or we provoke pain by pricking their finger. Whatever the reason it is our job as a health care professional to help ease their pain and anxiety.
Clinical reasoning in neonatology
Neonates are the masters of the nonspecific presentation- a high index of suspicion is required to identify the unwell neonate!
One of the keys to early recognition of a sick neonate is taking a history of ADL's:
If you don't know what normal feeding/eating/sleeping/crying is for a neonate, then how will you know what is abnormal?
Debriefing in the ED
Debriefing is a powerful tool that can be used after simulation training or real life critical events in the ED. It is designed to allow for discussion of processes, encouragement of reflection and implementation of a shared mental model of care. It is also something that we don't always do very well, and we might not know where to start with regards to implementation.
The preschool child presenting with wheeze is unlikely to have pneumonia
Wheeze is one of the most common presenting complaints in preschool aged children. These children are often febrile and have increased work of breathing at presentation, so there can be an urge to order a chest x-ray to exclude a bacterial pneumonia.
Metabolic and endocrine
When faced with a sick child, don't overlook "outside the box" diagnoses- think about surgars and salts - could this be an endocrine or metabolic presentation?
A simple point of care electrolytes will help point you in the right direction (i.e. If BGL is low or high or low Na etc).
Play therapy for pain relief
The role of play and distraction in paediatric patients when painful procedures are being carried out is highly underutilised. The attached study carried out a randomised control trial looking at the use of Entonox, play therapy, and a combination of the two during procedures.
Drug dosing cheat sheets
Below are some drug dosing cheat sheets - these are based off the Royal Children’s Hospital (Melbourne ) and Queensland Children's Hospital drug dosing guidelines. They are the size of an iPhone wallpaper.
If you are working in a children's ED or mixed department hopefully these can come in handy!
Clinical reasoning in Paediatric EM
You need to manage yourself hour by hour when it comes to clinical reasoning.
What subconscious influences are affecting you?
Nasal foreign bodies
Nasal foreign bodies are relatively common, particularly in inquisitive pre-school aged children.
Here, our friend Alex Blythe, demonstrates a simple technique to remove them.
All that wheezes is not asthma
Wheeze is a common presentation in paediatrics. Whilst it is most frequently seen in patients presenting with bronchiolitis, viral induced wheeze or asthma, there are other causes of wheeze that we should consider in our differential when these patients present.
Obesity in children and drug dosing
According to the Australian Institute of Health and Welfare, 25% of children and adolescents are classified as obese. Given that we rely on weight for drug dosing, how do we ensure that we keep our patients safe whilst still delivering effective drug doses?
What drugs doses should be adjusted and how should we do this?
Dr Danielle Scarfe