A retrospective study of infant chest CT scans using mathematical modelling and a number of assumptions suggests that neonatal CPR according to AAP/AHA guidelines of compressing to one third anteroposterior chest wall diameter should provide a superior ejection fraction to 1/4 depth and should generate less risk for over-compression than 1/2 AP compression depth.
Evaluation of the Neonatal Resuscitation Program’s recommended chest compression depth using computerized tomography imaging
Resuscitation. 2010 May;81(5):544-8
Compare their conclusions with those of the authors of this case series of arterial-line monitored cardiac arrests in infants with a median age of one month
Tag Archives: paediatric
Scalp veins
While clearing up after teaching with my bald colleague Dr Phil Hyde yesterday I noticed his bulging scalp veins and this reminded me that we don’t talk about this route much in our Paediatric Emergency Medicine Course.
This prompted me to look up the complications of scalp vein access in neonates and infants, which include:
- scalp abscess
- alopecia
- intracranial abscess
- thrombophlebitis
- intracranial venous sinus air embolism
- scalp necrotising fasciitis
Suggested ways to decrease the risk of complications include:
- A vein should not be used for more than 24 h at a time
- The needle entry point should not be covered
- The butterfly needle should be immobilized to avoid movements of the needle into the tissue with consequent extravasation of fluid
- The infusion site should be monitored by regular examination
- If a swelling or leakage of fluid is noted, the infusion should be discontinued immediately from that site
- The hair should be properly shaved
- If the line is required for more than 24 h, a peripheral venous cutdown or central venous line should be considered, after initial resuscitation
- An alternative route for rehydration (e.g. intraosseous infusion) should be considered initially, rather than risk multiple, unsuccessful attempts at scalp vein cannulation.
Complications of scalp vein infusion in infants
Trop Doct. 2005 Jan;35(1):46-7
Air emboli in the intracranial venous sinuses of neonates
Am J Perinatol. 2002 Jan;19(1):55-8
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:
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
A human suction unit for choking
A case is described of a 12 month old who completely obstructed her airway from an inhaled plastic ketchup container. As she did not improve with backslaps or chest thrusts her father, a physician, suctioned her airway using his own mouth (intermittently spitting out secretions) until the obstruction was relieved and the object removed. Something to think about if you’re at the end of your own child’s choking algorithm and you have no airway equipment with you.
Maneuver for the recovery of a foreign body causing a complete airway obstruction: illustrative case.
Pediatr Emerg Care. 2010 Jan;26(1):39-40
Extreme white cell counts
Febrile children aged three months to three years with a white cell count over 25000/mm3 and fever were compared with controls whose leucoytosis was less extreme (15000-24999). The ‘extreme’ group had serious bacterial infection (SBI) in 39% compared with 15.4% controls. Pneumonia was the commonest SBI.
The authors conclude that in febrile children aged 3–36 months, the presence of extreme leucocytosis is associated with a 39% risk of having SBIs. The increased risk for SBI is mainly due to a higher risk for pneumonia. I conclude that leucocytosis is like fever: the cause may be benign, but the higher the number the less likely that is, even though the majority still won’t have SBI.
Extreme leucocytosis and the risk of serious bacterial infections in febrile children
Arch Dis Child. 2010 Mar;95(3):209-12
Identifying sick kids is still difficult
A systematic review to identify clinical features that have value in confirming or excluding the possibility of serious infection in children presenting to ambulatory care settings resulted in the calculation of likelihood ratios. Clinical features with a positive likelihood ratio of more than 5.0 were deemed red flags (ie, warning signs for serious infection); features with a negative likelihood ratio of less than 0.2 were deemed rule-out signs.
The features identified in several studies as red flags were :
- Cyanosis (+LR range 2.66-52.20)
- Rapid breathing (+LR 1.26-9.78)
- Poor peripheral perfusion (+LR 2.39-38.80)
- Petechial rash (+LR 6.18-83.70)]
In one primary care study the following were identified as strong red flags:
- Parental concern (+LR 14.40, 95% CI 9.30-22.10)
- Clinician instinct (+LR 23.50, 95 % CI 16.80-32.70)
Temperature of 40 degrees C or more had value as a red flag in settings with a low prevalence of serious infection.
What about ruling out serious illness?
Unfortunately, no single clinical feature had rule-out value but some combinations can be used to exclude the possibility of serious infection-for example, pneumonia is very unlikely (-LR 0.07, 95% CI 0.01-0.46) if the child is not short of breath and there is no parental concern.
An accompanying editorial sums up the challenge of paediatric emergency medicine in a nutshell:
“What is clear is that in 2010 we do not know how to effectively recognise or rule out severe disease in ill children and what is more, we do not even have a cohesive national or even global research strategy to address this problem.”
Diagnostic value of clinical features at presentation to identify serious infection in children in developed countries: a systematic review.
Lancet. 2010 Mar 6;375(9717):834-45
Cricoid pressure squashes kids' airways
A bronchoscopic study of anaesthetised infants and children receiving cricoid pressure revealed the procedure to distort the airway or occlude it by more than 50% with as little as 5N of force in under 1s and between 15 and 25N in teenagers. Therefore forces well below the recommended value of 30 N will cause significant compression/distortion of the airway in a child
Effect of cricoid force on airway calibre in children: a bronchoscopic assessment
Br J Anaesth. 2010 Jan;104(1):71-4
Best position for RIJV cannulation in kids
In a study of anaesthetised infants and children, the right internal jugular vein as assessed by ultrasonography was measured with the head in the neutral position, and then at 40 degrees and 80 degrees of rotation to the contralateral side. The 40 degree position resulted in an increase in IJV diameter but with less overlap with the carotid artery than the 80 degree position. The authors conclude that rotating the head 40 degrees to the left results in the best balance of increased IJV diameter versus overlap with the carotid.
Effects of head rotation on the right internal jugular vein in infants and young children
Anaesthesia Volume 65, Issue 3, Pages 272-276
Epinephrine and Dexamethasone in Children with Bronchiolitis
A multicentre double blind trial in 800 infants with bronchiolitis aged between 6 weeks and 12 months compared placebo with nebulised adrenaline, oral dexamethasone, or both. Only the combination led to a decrease in the primary endpoint of reduced hospital admission up to 7 days after enrollment, with an absolute risk reduction of 9% (from 26 to 17%). They also found an apparent benefit from combined therapy on their secondary outcomes: infants in the combined treatment group were discharged earlier from medical care and resumed quiet breathing and normal feeding sooner than did those in the placebo group. When the analysis was adjusted for multiple comparisons, the apparent benefit did not reach statistical significance, leading the authors to recommend further study.
Epinephrine and Dexamethasone in Children with Bronchiolitis
N Engl J Med. 2009 May 14;360(20):2079-89