Things We Like This Month – July 2019
After the successes of #DFTB19, the team at Norwich PEM are expanding their content! We aren’t moving away from infographics, as we feel that they are a key part of what we do here, but we’d like to introduce a few more blog style updates, about what is happening in and around the world of acute paediatrics in this “Fine City”.
So, as our first foray, here is a quick rundown of the posts, papers and Twitter goings-on that have caught our eye this month!
Journal articles we like
The original FEAST trial was one of the more shocking publications in recent years in the paediatric world. Intravenous fluid boluses in the treatment of children with signs of circulatory collapse has been a mainstay of treatment of critically unwell children for years. This study in resource poor setting showed that in children who received fluid boluses (5% albumin or 0.9% saline) were significantly more likely to die within 48 hours than those who did not receive fluid boluses. The original study was not without its critics, who argued that the resource poor setting, high levels of malaria and non-standard definition of shock meant the results were not so easily translated to the developed world, however, it certainly added weight to a growing area of adult and paediatric literature that is suggestive that liberal use of IV fluids in critically ill children may do more harm than help.
In this reanalysis of the data from FEAST, the authors attempt to break down WHY children who received fluid boluses are more likely to die. They did this by inventing scoring systems for cardiovascular, neurological and respiratory function, and analysing the effects that fluid boluses had on these. The conclusion was that fluid boluses, both of saline and albumin improved cardiovascular scores, but worsened respiratory and neurological scores, and children with worse respiratory and neurological scores were significantly more likely to die. As ever, this is by no means an in-depth look at the paper, which definitely deserves it’s own analysis, but I think there are very interesting years to come with regards to fluid management in sepsis.
Gastro-oesophageal reflux is a common cause of parental anxiety and both inpatient and outpatient contact in paediatrics. Much like bronchiolitis, the evidence suggests that almost no interventions work, and if the child is healthy and gaining weight, we should not be getting involved. However, sitting on our hands is difficult, and often therapy for acid suppression is started. These medications are usually well tolerated in the short term, and therefore considered “safe” to trial.
This retrospective cohort study looked at fracture rates amongst a large cohort of children, to see if there was an association between taking these medications, and fracture rates, and found there was an association between the medications and fractures, worse if given longer courses, and if introduced earlier. Now, there are always inherent problems with cohort studies, and as we all know, correlation does not equal causation. However, this is an emerging body of evidence suggesting that these medications may have more unpleasant long term effects. Should we stop prescribing them? No, this study far from definitive, however, a serious thought to the risk/benefit balance should be had before reaching for that bottle of ranitidine.
#FOAMed content we like
A fantastic breakdown of the reanalysis of the FEAST paper linked above. As ever, if a paper is interesting to you, we recommend breaking it down yourself, and coming to your own conclusions, however, if pressed for time, the pre-eminent Twitter based myth-busting infectious diseases guru has a great write up for you.
We’ve got a lot better at reducing the need to inject local anaesthetic thanks to increasing use of wound glue and Lidocaine Adrenaline Tetracaine (LAT) gel but neither are suitable for oral mucosal lacerations. This article looks at a new needle free method for anaesthesia for this type of wound. The numbers are tiny (n=3) but the authors have had some success with it and may be worth a try in those cases where needles are an absolute no.
Being asked to look at rashes is one of the things that makes my heart sink. When everything is an erythematous maculopapular rash how on earth do you go about telling the difference between scarlet fever and slapped cheek? This excellent blog covers the common and important rashes you’ll come across in the ED and their management – it’s a must read for anyone starting in the ED this summer.
Podcasts we like
I am a completely unashamed fan-person of the PEM Playbook, as Tim’s fun style, editing and case-based discussion surrounding teaching make this podcast a brilliant resource for learning. This podcast is on this uncommon, but can’t miss diagnosis, myocarditis. A fantastic run-through of diagnosis, what features are common/uncommon, practical stabilisation, and physiology supporting inotropic support. Be sure to subscribe, as Tim is consistently putting out some of the best PEM content out there.
The idea of cognitive biases is something that I am only relatively recently come into contact with. The excellent Linda Dykes from Bangor ED speaks very openly about a near-miss incident brought on by decision making impaired by cognitive biases. In this talk, Kevin McCaffrey talks about his own experiences with decision making and cognitive biases, highlighting that almost every decision we make is biased in some way. What are your biases, and if we are aware of them, can we minimise their impact on our own decision making tree?