Child development milestones

Does anyone else find these hard to remember as a non-paediatrician?

I’ve written a crappy little poem to act as a mnemonic for some important milestones and age-related features pertinent to ED assessment and communication. If someone wants to turn it into something sounding more like Gangsta Rap it might catch on.

At zero months some tone is neat
And keep them pink and warm and sweet

At two months head control is more
and smiles are something to adore

At four months when they find things funny
They laugh and roll back from their tummy

Roll both ways when half a year
Hand to hand and turn to hear

Should be sitting up by nine
Put things in mouth and waving fine

Speaking when a year has passed
They’re crawling with a pincer grasp

They’ll walk alone at 15 months
And use a spoon to eat their lunch

By month eighteen they’ll point to faces
Scribble pics and climb staircases

At two they run and have some dress sense
Rides trike at three and speaks full sentence

At four they have imagination
From five you try negotiation

At months nine up to fifteen
Stranger anxiety’s often seen
Distraction helps things seem less mean
But you may need some ketamine

**2104 Update** The amazing Grace Leo has recorded this as a song. I have no idea why but I’m impressed as always by her creativity and drive.
Here it is:

The early management of unstable angina and NSTEMI

The UK’s National Institute for Clinical Excellence has produced evidence based guidelines on the early management of unstable angina and NSTEMI

Their ‘key priorities for implementation’ are:

  • As soon as the diagnosis of unstable angina or NSTEMI is made, and aspirin and antithrombin therapy have been offered, formally assess individual risk of future adverse cardiovascular events using an established risk scoring system that predicts 6-month mortality (for example, Global Registry of Acute Cardiac Events [GRACE]).
  • Consider intravenous eptifibatide or tirofiban as part of the early management for patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%), and who are scheduled to undergo angiography within 96 hours of hospital admission.
  • Offer coronary angiography (with follow-on PCI if indicated) within 96 hours of first admission to hospital to patients who have an intermediate or higher risk of adverse cardiovascular events (predicted 6-month mortality above 3.0%) if they have no contraindications to angiography (such as active bleeding or comorbidity). Perform angiography as soon as possible for patients who are clinically unstable or at high ischaemic risk.
  • When the role of revascularisation or the revascularisation strategy is unclear, resolve this by discussion involving an interventional cardiologist, cardiac surgeon and other healthcare professionals relevant to the needs of the patient. Discuss the choice of the revascularisation strategy with the patient.
  • To detect and quantify inducible ischaemia, consider ischaemia testing before discharge for patients whose condition has been managed conservatively and who have not had coronary angiography.
  • Before discharge offer patients advice and information about:

– their diagnosis and arrangements for follow-up

– cardiac rehabilitation

– management of cardiovascular risk factors and drug therapy for secondary prevention

– lifestyle changes

One of the most potentially confusing areas is the choice of antithrombin therapy. Whereas the low molecular weight heparin enoxaparin is currently widely used, the guideline recommends the following:

The guideline summary is here and the full guideline is here

Single-use Metal Laryngoscope Blades

In a randomised study of more than 1072 patients for emergency intubation using rapid sequence induction, single-use metal blades were associated with fewer failed first attempts and fewer poor grade laryngeal views than reusable metal blades. Improved illumination may be a factor.
Comparison of Single-use and Reusable Metal Laryngoscope Blades for Orotracheal Intubation during Rapid Sequence Induction of Anesthesia
Anesthesiology. 2010 Feb;112(2):325-32

International Carotid Stenting Study (ICSS)

Patients with symptomatic severe carotid artery stenosis do better with carotid endarterectomy than with medical therapy alone. Surgical complications such as bleeding and cranial nerve damage make the alternative strategy of carotid stenting attractive, but a new randomised trial of 1710 patients with over 50% stenosis and symptoms suggests otherwise.

In favour of stenting, there was one event of cranial nerve palsy in the stenting group compared with 45 in the endarterectomy group, and fewer haematomas of any severity in the stenting group than in the endarterectomy group (31 vs 50 events; p=0.0197).

However the incidence of stroke, death, or procedural myocardial infarction was 8.5% in the stenting group compared with 5.2% in the endarterectomy group (72 vs 44 events; HR 1.69, 1.16-2.45, p=0.006). Risks of any stroke (65 vs 35 events; HR 1.92, 1.27-2.89) and all-cause death (19 vs seven events; HR 2.76, 1.16-6.56) were higher in the stenting group than in the endarterectomy group. Three procedural myocardial infarctions were recorded in the stenting group, all of which were fatal, compared with four, all non-fatal, in the endarterectomy group.

The authors point out that longer term follow up remains to be looked at, but that carotid endarterectomy should remain the treatment of choice for symptomatic patients with severe carotid stenosis suitable for surgery. However most patients had no complications from either procedure and stenting is also likely to be better than no revascularisation in patients unwilling or unable to have surgery because of medical or anatomical contraindications.

Carotid artery stenting compared with endarterectomy in patients with symptomatic carotid stenosis (International Carotid Stenting Study): an interim analysis of a randomised controlled trial
Lancet. 2010 Mar 20;375(9719):985-97

Kids need ‘proper’ CPR if non-cardiac cause of arrest

The American Heart Association recommends cardiopulmonary resuscitation (CPR) by bystanders with chest compression only for adults who have cardiac arrests, but not for children. These recommendations have new support in a large observational study from Japan examining outcomes in 5170 out-of hospital paediatric arrests over a 3 year period.
For children who had out-of-hospital cardiac arrests from non-cardiac causes, conventional CPR (with rescue breathing) by bystander was associated with improved outcomes compared with compression-only CPR (7·2% [45/624] favourable one month neurological outcome vs 1·6% [6/380]; OR 5·54, 2·52–16·99). In children who had arrests of cardiac causes conventional and compression-only CPR were similarly effective. Infants < 1 year had uniformly poor outcomes.

An editorial points out that this is the largest study that has analysed out-of-hospital cardiac arrest in children, and the overall survival of 9% with only 3% of children having a good neurological outcome, is consistent with previous reports.

Conventional and chest-compression-only cardiopulmonary resuscitation by bystanders for children who have out-of-hospital cardiac arrests: a prospective, nationwide, population-based cohort study
Lancet. 2010 Apr 17 345:1347-54

2000 vs 2005 VF guidelines: RCT

One of the key changes in international resuscitation guidelines between the 2000 and 2005 has been to minimise potentially deleterious hands-off time, so that CPR is interrupted less for pulse checks and DC shocks.

These two approaches have been compared in a randomised controlled trial of 845 patients in France requiring out of hospital defibrillation, in which the control group were shocked using AEDs with prompts based on the 2000 guidelines (3 stacked shocks before CPR resumed, and pulse checks done), and the intervention group were shocked using devices that prompted according to the 2005 guidelines, in which there were fewer and shorter intervals for which the AED required the rescuer to stay clear of the patient (single shocks, no pulse checks).

There was no difference in the primary endpoint of survival to hospital admission (43.2% versus 42.7%; p=0.87), or in survival to hospital discharge (13.3% versus 10.6%; p=0.19). The study was not powered to assess one year survival. In the authors’ words: “our randomized controlled trial now provides more definitive evidence that this combination of Guidelines 2005 CPR protocol changes does not measurably improve outcome. Although the protocol changes accomplish the desired effect of increasing chest compressions, they may also cause other effects, such as earlier refibrillation and more time spent in VF, with as yet unknown consequences.

Interestingly the Cardio-pump was used in this study to provide chest compressions, which is an active compression-decompression device, potentially limiting the generalisability of the findings to manual compression-only CPR situations. Potential bias was also introduced by the exclusion of patients in whom consent from relatives was not obtained. Nevertheless it’s good to see such rigorous clinical research applied to this area.

DEFI 2005. A Randomized Controlled Trial of the Effect of Automated External Defibrillator Cardiopulmonary Resuscitation Protocol on Outcome From Out-of-Hospital Cardiac Arrest
Circulation. 2010;121:1614-1622

Antibiotics for severe burns yes or no?

Should prophylactic antibiotics be given to burns patients? A systematic review of 17 trials concludes they may reduce all-cause mortality when given for 4-14 days after admission; there was a reduction in pneumonia with systemic prophylaxis and a reduction in wound infections with perioperative prophylaxis. However the overall methodological quality of the trials was poor and in three trials, resistance to the antibiotic used for prophylaxis significantly increased. The authors consequently do not recommend prophylaxis for patients with severe burns other than perioperatively.

Take home message: not needed as part of critical care resuscitation

Prophylactic antibiotics for burns patients: systematic review and meta-analysis
BMJ. 2010 Feb 15;340:c241

Battlefield resuscitation

An excellent review of the current British military practice to prevent and treat the acute coagulopathy of trauma shock (ACoTS) describes pathophysiology and treatment options and offers an algorithm for management. Key components of the system (when indicated according to their algorithm) outlined include:

  • Pre-hospital damage control shock resuscitation by a forward medical team, consisting of RSI with reduced dose thio or ketamine with suxamethonium or rocuronium, large bore sublclavian access, and early use of warmed blood products
  • 1:1:1 packed red cells, fresh frozen plasma, and platelets,
  • Cryoprecipitate
  • Tranexamic acid
  • Recombinant activated factor VII
  • Permissive hypotension aiming for a systolic BP of 90 mmHg, using blood products and avoiding vasopressors according to a ‘flow rather than pressure’ philosophy
  • Avoiding hypothermia by giving warmed blood products and employing active patient warming methods
  • Buffering acidosis using Tris-hydroxymethyl aminomethane (THAM), which may be superior to bicarbonate by not affecting minute ventilation or coagulation, and maintaining its efficacy in hypothermic conditions
  • Minimising hypoperfusion with an anaesthetic strategy that provides effective analgesia and vasodilation, using high dose fentanyl and a low concentration volatile agent
  • Using fresh whole blood for resistant coagulopathy

Battlefield resuscitation
Curr Opin Crit Care. 2009 Dec;15(6):527-35

Sorting ABCD issues pre-hospital

Prospectively collected data on 727 major trauma patients from a Portugese trauma centre registry enabled the comparison of mortality between three groups of patients with a priori defined life threatening ‘ABCD’ problems: those whose ABCD issues were treated in the field by a pre-hospital emergency physician, those that were treated at another hospital prior to trauma centre transfer, and those whose ABCD issues were first treated on arrival at the trauma centre. The study population included mixed urban and rural trauma.

Patients from the pre-hospital and first hospital groups had 20% and 27% mortality respectively, compared to 38% among those whose life-threatening events were corrected only at the trauma centre.

Patients whose life- threatening events were treated in the pre-hospital environment had lower mortality but at the same time were younger and less severely injured, so a multivariate logistic regression was performed to adjust the odds of death to patient characteristics and trauma severity as well as time from accident to trauma centre. Logistic regression showed that increases in mortality were associated with female gender and older age, penetrating type of trauma, higher anatomic severity (ISS), higher physiological severity (RTS) and having the life-threatening events corrected only at the trauma centre. Logistic regression showed that patients whose life-threatening events were corrected only at the trauma centre had an odds of death 3.3 times greater than those from the pre-hospital group, adjusted for patient and trauma characteristics and time to trauma centre.

Correcting life-threatening events pre- trauma centre (pre-hospital and first hospital) increased the total time from the accident to trauma centre, but long pre-hospital times were not associated with worse outcome.

The importance of pre-trauma centre treatment of life-threatening events on the
mortality of patients transferred with severe trauma

Resuscitation. 2010 Apr;81(4):440-5

Normal ECG still doesn’t rule out PE

ECGs from a prospective study of patients in the ED with suspected pulmonary embolism were studied to identify the relative frequency of ECG features of pulmonary hypertension. For a patient to be eligible for enrollment, a physician was required to have sufficient suspicion for pulmonary embolism to order objective diagnostic testing in the ED. Such testing included D-dimer measurement, computed tomography pulmonary angiography, ventilation/perfusion scanning, or venous ultrasonography.

ECGs were done in 6049 patients, 354 (5.9%) of whom were diagnosed with pulmonary embolism. The frequency, positive likelihood ratio (LR+) and 95% confidence interval (CI) of each predictor were as follows:

  • S1Q3T3 8.5% with pulmonary embolism versus 3.3% without pulmonary embolism (LR+ 3.7; 95% CI 2.5 to 5.4)
  • nonsinus rhythm, 23.5% versus 16.6% (LR+ 1.4; 95% CI 1.2 to 1.7)
  • inverted T waves in V1 to V2, 14.4% versus 8.1% (LR+ 1.8; 95% CI 1.3 to 2.3)
  • inversion in V1 to V3, 10.5% versus 4.0% (LR+ 2.6; 95% CI 1.9 to 3.6)
  • inversion in V1 to V4, 7.3% versus 2.0% (LR+ 3.7; 95% CI 2.4 to 5.5)
  • incomplete right bundle branch block, 4.8% versus 2.8% (LR+ 1.7; 95% CI 1.0 to 2.7)
  • tachycardia (pulse rate>100 beats/min), 28.8% versus 15.7% (LR+ 1.8; 95% CI 1.5 to 2.2).

The authors point out that the study may be subject to reporting bias or incorporation bias because those patients with ECG abnormalities may have then been more likely to undergo further evaluation for PE.

Overall, they summarise that the main findings were that the S1Q3T3 pattern and precordial T-wave inversions had the highest LR(+) values with lower-limit 95% CIs above unity, whether or not the patient had preexisting cardiopulmonary disease, but emphasise that the sensitivities of each of these findings were low, and clinicians should not decrease their suspicion for pulmonary embolism according to their absence.

Likelihood ratios and specificities were similar when patients with previous cardiopulmonary disease were excluded from analysis.
12-Lead ECG Findings of Pulmonary Hypertension Occur More Frequently in Emergency Department Patients With Pulmonary Embolism Than in Patients Without Pulmonary Embolism
Ann Emerg Med. 2010 Apr;55(4):331-5