Paediatric Head Injury and Traumatic Brain Injury

Aim To determine prevalence of head injury presenting to paediatric emergency departments (PEDs) and characterise by demographics, triage category, disposition neuroimaging or re-attendance. Methods Presentations in 2014 and 2015, with diagnoses of head injury, intracranial bleed, skull fracture including single or re-attendances within 28 days post head injury to all national PEDs, were analysed. Demographics, triage score, imaging rate, admission, mechanisms and representation rate were recorded. Results Head injury was diagnosed in 13,392 of 224,860 (5.9%), median (IQR) age 3.9 (1.4 - 8.3) years. Regionally 3% of children <5 years attend each year. The total admitted/transferred was 10.8% (n=1460). Neuroimaging rate was 4.3% (n= 570). Falls predominated. Sport accounted for 12.2%. Conclusion One in twenty children PED presentations are head injury, over half in preschool children. A sizeable number were symptomatic reflected by admission, transfer, imaging or re-attendance. Observational management was favoured over imaging reflected in the higher admission versus imaging rate.

Paediatric Early Warning Trigger--A Cry for Help

In paediatrics, it is crucial to ensure that the child who is clinically deteriorating is rapidly recognised and treated. We implemented a Paediatric Early Warning Trigger (PEWT) in our unit to improve recognition of these patients. Our trigger was a series of physiological measurements with a PEWT call if any result was outside the accepted range. We retrospectively compared 12 months prior to the introduction of the trigger (January to December 2009) to the three years post the introduction of the trigger (January 2010 to December 2012). We compared the time from deterioration to involvement of senior staff during the two time periods. We also examined the rates of crash calls and PICU transfers in the two periods. We found that the time from deterioration to senior clinician involvement reduced from 312 minutes to 166 minutes and the rate of transfers to PICU among the triage category 1 & 2 patients reduced from 1:50 in 2009 to 1:129, 1:118 and 1:131 during the three years of the trial. The rate of cardiac arrest among this group reduced from 1:100 in 2009 to 1:129, 1:216 and 1:542 during the three years of the trial. This study demonstrates the effectiveness of a Paediatric Early Warning Trigger in an Irish setting. We have been able to maximise senior clinician input into our sickest children in a more timely fashion

The compliance to acute asthma management protocols in paediatric emergency department

Asthma guidelines should be followed closely to ensure improvement and consistency of outcome. In order to measure compliance with local acute asthma protocols, we reviewed notes of children presenting to our ED with acute asthma. We noted clinical assessment of severity of asthma exacerbation, compared management of cases with local protocols, noted time to first nebulisation, discharge advice and follow up plans. Retrospectively, 6 patients had life-threatening, 70 had severe and 64 had mild-to-moderate exacerbation. We observed inconsistent documentation of clinical signs including, respiratory effort 6 (100%), 62 (89%), 39 (61%), mental status 3 (50%), 46 (65%), 47 (73%) and speech 1 (16.7%), 19 (27%), 7 (11%) in life threatening, severe and mild-to-moderate groups respectively. Bronchodilator therapy was delayed in life-threatening 3 (50%) and severe cases 63 (90%). While discharge advice was documented in 54% patients, no written asthma action plans were given. This study demonstrated necessity of protocol-adherence in areas of clinical assessment, management and follow up.

Complications associated with the bacille Calmette-Guérin vaccination in Ireland

INTRODUCTION

BCG vaccination is currently recommended for all newborns in Ireland except where specifically contraindicated. This paper describes a marked increase in the number of referrals of patients with localised complications after vaccination to two Dublin paediatric hospitals. This increase coincided with the introduction of a new strain of BCG vaccine

METHODS

A population surveillance study was undertaken to determine the frequency and spectrum of complications associated with the new strain of BCG vaccine introduced in Ireland. Patients were identified though review of the infectious disease service case records and microbiology laboratory culture reports for the two year period from August 2002 to July 2004. Prospectively gathered data were supplemented by retrospective chart review. All infants who had inoculation site abscesses, suppurative adenopathy, or non-suppurative adenopathy with nodes > or =2 cm were included.

RESULTS

Fifty eight patients presented a median of 13 weeks post-inoculation: 32 with suppurative adenitis, 17 with inoculation site abscess, three with both inoculation site abscess and suppurative adenitis, and six with non-suppurative adenopathy. The overall complication rate was estimated at 1/931 vaccinees with 1/1543 developing suppurative adenitis. Twenty six infants required surgery.

DISCUSSION

This series illustrates the role of hospitals in sentinel surveillance and highlights the importance of having a well functioning and responsive system of adverse event reporting. These events raise a serious question as to the suitability of this vaccine strain for use in a national immunisation programme in a country where the prevalence of tuberculous disease is 10.4/100,000.

Modes of death in neonatal intensive care units

With the ever-increasing availability of aggressive medical treatment and technical support, neonatologists are offered an increasing ability to prolong life. While "end-of-life" decisions within NICUs have been studied internationally, there is limited data available for Ireland. Through the auspices of the Irish Faculty of Paediatrics 2002 Neonatal Mortality Ouestionnaire, decisions made around the time of death in Irish Neonatal Intensive Care Units were examined. The overall response rate to the questionnaire was 96% (n=25). One hundred and eighty seven deaths were reported for 2002. Information pertaining to the mode of death was available in 53% of cases. Seventy seven percent of those paediatricians who answered this question, reported either withdrawing or withholding treatment in babies thought to have a hopeless outcome, with the greatest proportion of these deaths occurring in premature infants (n=30) and babies with congenital defects (n=40).