Finding the sick febrile kid

Finding children with serious illness among the multitudes who present with fever is the number one challenge in paediatric emergency medicine.
A two year prospective cohort study was conducted at the Children’s Hospital Westmead in Sydney to develop and test a multivariable model to distinguish serious bacterial infections from self limiting non-bacterial illnesses.
A standardised clinical evaluation that included mandatory entry of 40 clinical features was recorded by physicians on around 15000 febrile kids under age 5. Clinical, laboratory and radiological follow up was undertaken to identify one of three key types of serious bacterial infection (SBI): urinary tract infection, pneumonia, and bacteraemia.

7.2% had SBI – urinary tract infection 3.4%, pneumonia 3.4%, and bacteraemia 0.4%.
A diagnostic model was developed using multinomial logistic regression methods. Physicians’ diagnoses of bacterial infection had low sensitivity (10-50%) and high specificity (90-100%), whereas the clinical diagnostic model provided a broad range of values for sensitivity and specificity.
The authors suggest that a computer assisted diagnostic decision tool could be used to determine the likelihood of serious bacterial infection.
The strongest positive predictors of serious bacterial infection were a generally very unwell appearance, high temperature, chronic disease, and prolonged capillary refill time. For children with pneumonia, other predictors were coughing, difficulty breathing, abnormal chest sounds, and to a lesser extent tachypnoea, chest crackles, and tachycardia. For urinary tract infection, the presence of urinary symptoms was by far the strongest indicator, whereas for bacteraemia, tachycardia and crying were also strong indicators although an editorial points out that only 64 cases of bacteraemia occurred, so this last result should be treated with caution.
The accuracy of clinical symptoms and signs for the diagnosis of serious bacterial infection in young febrile children: prospective cohort study of 15 781 febrile illnesses
BMJ. 2010 Apr 20;340:c1594

Unexpected survivors after pre-hospital intubation

Data on patients with moderate to severe traumatic brain injury from the San Diego Trauma Registry were analysed using modified TRISS methodology to determine predicted survival, from which an observed-predicted survival differential (OPSD) was calculated. The mean OPSD was calculated as the primary outcome for the following comparisons: intubated versus nonintubated, air versus ground transport, eucapnia (PCO2 30–50 mm Hg) versus noneucapnia, and hypoxemia (PO<90 mm Hg) versus nonhypoxemia. Of note in this region is that ground EMS staff intubate without drugs, whereas air medical services use rapid sequence intubation with suxamethonium plus either etomidate or midazolam. The rationale behind this methodology was to eliminate the possible selection bias present in previous studies linking pre-hospital intubation with mortality (sicker patients are able to be intubated without drugs). A total of 9,018 TBI patients had complete data to allow calculation of probability of survival using TRISS. A total of 16.7% of patients were intubated in the field; 49.6% of these were transported by air medical providers. Patients undergoing prehospital intubation, transported by ground, with arrival eucapnia, and without arrival hypoxemia had higher mean OPSD values. Intubated patients were more likely to be “unexpected survivors” and live to hospital discharge despite low predicted survival values; patients transported by air medical personnel had higher OPSD values and had a higher proportion of unexpected survivors. No statistically significant differences were observed between air- and ground-transported patients with regard to arrival PCO2 values arrival PO2 values. Prehospital Airway and Ventilation Management: A Trauma Score and Injury Severity Score-Based Analysis
J Trauma. 2010 Aug;69(2):294-301

New ICH Guidelines

A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association on the management of spontaneous intracerebral haemorrhage has been published in Stroke. The full text is available here.
In summary:
Medical Treatment for ICH

  • Patients with a severe coagulation factor deficiency or severe thrombocytopenia should receive appropriate factor replacement therapy or platelets, respectively
  • Patients with ICH whose INR is elevated due to oral anticoagulants (OAC) should have their warfarin withheld, receive therapy to replace vitamin K–dependent factors and correct the INR, and receive intravenous vitamin K. Prothrombin Complex Concentrates have not shown improved outcome compared with FFP but may have fewer complications compared with FFP and are reasonable to consider as an alternative to FFP.
  • rFVIIa does not replace all clotting factors, and although the INR may be lowered, clotting may not be restored in vivo; therefore, rFVIIa is not routinely recommended as a sole agent for OAC reversal in ICH
  • Although rFVIIa can limit the extent of hematoma expansion in noncoagulopathic ICH patients, there is an increase in thromboembolic risk with rFVIIa and no clear clinical benefit in unselected patients. Thus rFVIIa is not recommended in unselected patients. Further research to determine whether any selected group of patients may benefit from this therapy is needed before any recommendation for its use can be made.
  • The usefulness of platelet transfusions in ICH patients with a history of antiplatelet use is unclear and is considered investigational
  • Patients with ICH should have intermittent pneumatic compression for prevention of venous thromboembolism in addition to elastic stockings
  • After documentation of cessation of bleeding, low-dose subcutaneous low-molecular-weight heparin or unfractionated heparin may be considered for prevention of venous thromboembolism in patients with lack of mobility after 1 to 4 days from onset
  • Blood Pressure

    • Until ongoing clinical trials of BP intervention for ICH are completed, physicians must manage BP on the basis of the present incomplete efficacy evidence. Current suggested recommendations for target BP in various situations are listed in an accompanying table and may be considered
    • In patients presenting with a systolic BP of 150 to 220 mmHg, acute lowering of systolic BP to 140 mm Hg is probably safe

    Inpatient Management and Prevention of Secondary Brain Injury

    • Initial monitoring and management of ICH patients should take place in an intensive care unit with physician and nursing neuroscience intensive care expertise
    • Glucose should be monitored and normoglycemia is recommended

    Seizures and Antiepileptic Drugs

    • Clinical seizures should be treated with antiepileptic drugs
    • Continuous EEG monitoring is probably indicated in ICH patients with depressed mental status out of proportion to the degree of brain injury
    • Patients with a change in mental status who are found to have electrographic seizures on EEG should be treated with antiepileptic drugs
    • Prophylactic anticonvulsant medication should not be used


    • Patients with a GCS score of ≤8, those with clinical evidence of transtentorial herniation, or those with significant IVH or hydrocephalus might be considered for ICP monitoring and treatment. A cerebral perfusion pressure of 50 to 70 mmHg may be reasonable to maintain depending on the status of cerebral autoregulation
    • Ventricular drainage as treatment for hydrocephalus is reasonable in patients with decreased level of consciousness

    Intraventricular Hemorrhage Recommendation

    • Although intraventricular administration of recombinant tissue-type plasminogen activator in IVH appears to have a fairly low complication rate, efficacy and safety of this treatment is uncertain and is considered investigational

    Clot Removal

    • For most patients with ICH, the usefulness of surgery is uncertain. Specific exceptions to this recommendation follow
    • Patients with cerebellar hemorrhage who are deteriorating neurologically or who have brainstem compression and/or hydrocephalus from ventricular obstruction should undergo surgical removal of the hemorrhage as soon as possible. Initial treatment of these patients with ventricular drainage alone rather than surgical evacuation is not recommended
    • For patients presenting with lobar clots ≥30 mL and within 1 cm of the surface, evacuation of supratentorial ICH by standard craniotomy might be considered
    • The effectiveness of minimally invasive clot evacuation utilizing either stereotactic or endoscopic aspiration with or without thrombolytic usage is uncertain and is considered investigational
    • Although theoretically attractive, no clear evidence at present indicates that ultra-early removal of supratentorial ICH improves functional outcome or mortality rate. Very early craniotomy may be harmful due to increased risk of recurrent bleeding

    Outcome Prediction and Withdrawal of Technological Support

    • Aggressive full care early after ICH onset and postponement of new DNR orders until at least the second full day of hospitalization is probably recommended. Patients with preexisting DNR orders are not included in this recommendation. Current methods of prognostication in individual patients early after ICH are likely biased by failure to account for the influence of withdrawal of support and early DNR orders. Patients who are given DNR status at any point should receive all other appropriate medical and surgical interventions unless otherwise explicitly indicated.

    Prevention of Recurrent ICH

    • In situations where stratifying a patient’s risk of recurrent ICH may affect other management decisions, it is reasonable to consider the following risk factors for recurrence: lobar location of the initial ICH, older age, ongoing anticoagulation, presence of the apolipoprotein ε2 or ε4 alleles, and greater number of microbleeds on MRI
    • After the acute ICH period, absent medical contraindications, BP should be well controlled, particularly for patients with ICH location typical of hypertensive vasculopathy
    • After the acute ICH period, a goal target of a normal BP of <140/90 (<130/80 if diabetes or chronic kidney disease) is reasonable
    • Avoidance of long-term anticoagulation as treatment for nonvalvular atrial fibrillation is probably recommended after spontaneous lobar ICH because of the relatively high risk of recurrence. Anticoagulation after nonlobar ICH and antiplatelet therapy after all ICH might be considered, particularly when there are definite indications for these agents. Avoidance of heavy alcohol use can be beneficial. There is insufficient data to recommend restrictions on use of statin agents or physical or sexual activity

    Rehabilitation and Recovery

    • Given the potentially serious nature and complex pattern of evolving disability, it is reasonable that all patients with ICH have access to multidisciplinary rehabilitation. Where possible, rehabilitation can be beneficial when begun as early as possible and continued in the community as part of a well-coordinated (seamless) program of accelerated hospital discharge and home-based resettlement to promote ongoing recovery

    Guidelines for the Management of Spontaneous Intracerebral Hemorrhage. A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association
    Stroke published online Jul 22, 2010

    Decompressive craniectomy

    Neuro-folks at LAC+USC Medical Centre describe outcomes for patients with traumatic brain injury without space-occupying haemorrhage who underwent decompressive craniectomy for intracranial hypertension refractory to maximal medical therapy. Of 43 included patients, 25.6% died (11 of 43), and 32.5% (14 of 43) remained in vegetative state or were severely disabled. Favourable outcome (Glasgow Outcome Scale 4 and 5) was observed in 41.9% (18 of 43). More evidence will result from two ongoing randomised multicentre trials: the European RescueICP study and the Australian DECRA trial.

    Decompressive craniectomy: Surgical control of traumatic intracranial hypertension may improve outcome
    Injury. 2010 Jul;41(7):934-8

    Balloon pump before PCI? Nah.

    High risk patients benefit from pre-operative intra-aortic balloon counterpulsation (IABP) prior to coronary artery bypass surgery. Would the same apply to patients undergoing percutaneous coronary intervention (PCI)?
    A multicentre randomised controlled trial was conducted on over 300 patients with severe LV dysfunction and extensive coronary disease. The intervention was elective insertion of IABP before PCI. The composite primary end point of death, acute myocardial infarction, cerebrovascular event, or further revascularization at hospital discharge was not reduced in the intervention group.
    These results do not support a strategy of routine IABP placement before PCI in all patients with severe left ventricular dysfunction and extensive coronary disease.
    Elective Intra-aortic Balloon Counterpulsation During High-Risk Percutaneous Coronary Intervention
    JAMA. 2010;304(8):867-874

    ACE-inhibitor related angioedema

    The pathophysiology of angiotensin-converting enzyme inhibitor (ACEi)–induced angioedema most likely resembles that of hereditary angioedema, ie, it is mainly mediated by bradykinin-induced activation of vascular bradykinin B2 receptors. It was hypothesised that the bradykinin B2 receptor antagonist icatibant might therefore be an effective therapy for ACEi-induced angioedema. This month’s Annals of Emergency Medicine reports research assessing its effciacy in a small series of patients, with a retrospective comparison against steroid and antihistamine therapy.
    The eight patients with acute ACEi-induced angioedema were treated with a single subcutaneous injection of icatibant. First symptom improvement after icatibant injection occurred at a mean time of 50.6 minutes and complete relief of symptoms at 4.4 hours. In the historical comparison group treated with methylprednisolone and clemastine (an antihistamine / anticholinergic), the mean time to complete relief of symptoms was 33 hours. Some of these patients received a tracheotomy (3/47), were intubated (2/47), or received a second dose of methylprednisolone (12/47).
    Therapeutic Efficacy of Icatibant in Angioedema Induced by Angiotensin-Converting Enzyme Inhibitors: A Case Series
    Ann Emerg Med. 2010;56(3):278-82

    UK Capacity Assessment Mnemonic

    GPs Drs Hoghton & Chadwick have produced a bioethical mnemonic ‘CURB BADLIP’, for all healthcare professionals in England, Scotland, and Wales for use in patients aged 18 or over in an emergency:

    C—communicate. Can the person communicate his or her decision?
    U—understand. Can the person understand the information being given?
    R—retain. Can the person retain the information given?
    B—balance. Can the person balance, or use, the information?
    B—best interest. If there is no capacity can you make a best interest decision?
    AD—advanced decision. Is there an advanced decision to refuse treatment?
    L—lasting power of attorney. Has lasting power of attorney been appointed?
    I—independent mental capacity advocate. Is the person without anyone who can be consulted about best interest? In an emergency involve an independent mental capacity advocate
    P—proxy. Are there any unresolved conflicts? Consider involving the local ethics committee or the court of protection appointed deputy.

    Assessing patient capacity: Remember CURB BADLIP in the UK
    BMJ 2010 340: c1285

    Delirium guidelines

    The UK’s National Institute for Health and Clinical Excellence (NICE) has produced guidelines on delirium.
    Delirium (sometimes called ‘acute confusional state’) is a common clinical syndrome characterised by disturbed consciousness, cognitive function or perception, which has an acute onset and fluctuating course.
    Some snippets from the guideline include:

    • If indicators of delirium are identified, carry out a clinical assessment based on the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) criteria or short Confusion Assessment Method (short CAM) to confirm the diagnosis.
    • In critical care or in the recovery room after surgery, CAM-ICU should be used. A healthcare professional who is trained and competent in the diagnosis of delirium should carry out the assessment.
    • If there is difficulty distinguishing between the diagnoses of delirium, dementia or delirium superimposed on dementia, treat for delirium first.
    • If a person with delirium is distressed or considered a risk to themselves or others and verbal and non-verbal de-escalation techniques are ineffective or inappropriate, consider giving short- term (usually for 1 week or less) haloperidol or olanzapine.

    The CAM-ICU assessment tool is demonstrated in the video below, which is found along with other helpful delirium resources at

    NICE Guidance: Delirium: diagnosis, prevention and management

    Compression-only CPR vs standard CPR

    Two studies comparing compression-only CPR with conventional CPR:

    BACKGROUND: The role of rescue breathing in cardiopulmonary resuscitation (CPR) performed by a layperson is uncertain. We hypothesized that the dispatcher instructions to bystanders to provide chest compression alone would result in improved survival as compared with instructions to provide chest compression plus rescue breathing.
    METHODS: We conducted a multicenter, randomized trial of dispatcher instructions to bystanders for performing CPR. The patients were persons 18 years of age or older with out-of-hospital cardiac arrest for whom dispatchers initiated CPR instruction to bystanders. Patients were randomly assigned to receive chest compression alone or chest compression plus rescue breathing. The primary outcome was survival to hospital discharge. Secondary outcomes included a favorable neurologic outcome at discharge.
    RESULTS: Of the 1941 patients who met the inclusion criteria, 981 were randomly assigned to receive chest compression alone and 960 to receive chest compression plus rescue breathing. We observed no significant difference between the two groups in the proportion of patients who survived to hospital discharge (12.5% with chest compression alone and 11.0% with chest compression plus rescue breathing, P=0.31) or in the proportion who survived with a favorable neurologic outcome in the two sites that assessed this secondary outcome (14.4% and 11.5%, respectively; P=0.13). Prespecified subgroup analyses showed a trend toward a higher proportion of patients surviving to hospital discharge with chest compression alone as compared with chest compression plus rescue breathing for patients with a cardiac cause of arrest (15.5% vs. 12.3%, P=0.09) and for those with shockable rhythms (31.9% vs. 25.7%, P=0.09).
    CONCLUSIONS: Dispatcher instruction consisting of chest compression alone did not increase the survival rate overall, although there was a trend toward better outcomes in key clinical subgroups. The results support a strategy for CPR performed by laypersons that emphasizes chest compression and minimizes the role of rescue breathing. (Funded in part by the Laerdal Foundation for Acute Medicine and the Medic One Foundation; number, NCT00219687.)

    CPR with chest compression alone or with rescue breathing
    N Engl J Med. 2010 Jul 29;363(5):423-3

    BACKGROUND: Emergency medical dispatchers give instructions on how to perform cardiopulmonary resuscitation (CPR) over the telephone to callers requesting help for a patient with suspected cardiac arrest, before the arrival of emergency medical services (EMS) personnel. A previous study indicated that instructions to perform CPR consisting of only chest compression result in a treatment efficacy that is similar or even superior to that associated with instructions given to perform standard CPR, which consists of both compression and ventilation. That study, however, was not powered to assess a possible difference in survival. The aim of this prospective, randomized study was to evaluate the possible superiority of compression-only CPR over standard CPR with respect to survival.
    METHODS: Patients with suspected, witnessed, out-of-hospital cardiac arrest were randomly assigned to undergo either compression-only CPR or standard CPR. The primary end point was 30-day survival.
    RESULTS: Data for the primary analysis were collected from February 2005 through January 2009 for a total of 1276 patients. Of these, 620 patients had been assigned to receive compression-only CPR and 656 patients had been assigned to receive standard CPR. The rate of 30-day survival was similar in the two groups: 8.7% (54 of 620 patients) in the group receiving compression-only CPR and 7.0% (46 of 656 patients) in the group receiving standard CPR (absolute difference for compression-only vs. standard CPR, 1.7 percentage points; 95% confidence interval, -1.2 to 4.6; P=0.29).
    CONCLUSIONS: This prospective, randomized study showed no significant difference with respect to survival at 30 days between instructions given by an emergency medical dispatcher, before the arrival of EMS personnel, for compression-only CPR and instructions for standard CPR in patients with suspected, witnessed, out-of-hospital cardiac arrest. (Funded by the Swedish Heart–Lung Foundation and others; Karolinska Clinical Trial Registration number, CT20080012.)

    Compression-Only CPR or Standard CPR in Out-of-Hospital Cardiac Arrest
    N Engl J Med. 2010 Jul 29;363(5):434-42

    Cuffed vs. uncuffed tubes in kids

    The debate considering cuffed vs uncuffed tracheal tubes in children continues in some centres. In my view the argument for cuffed tubes in the emergency medicine setting is much stronger.
    I found an online presentation by Patrick Ross, MD, on the subject which includes a nice summary of recent literature. I like his take home message:
    If they are coming to the ICU, if they may be difficult to ventilate, if I only want to intubate once – I use a cuffed tube
    Cuffed vs. Uncuffed ETT