Breaking Evidence: EuSEM top scoring PEM abstracts 4-6

“Characteristics and outcomes of paediatric emergencies in Nicaragua” by Silvia Bressan (MD, PhD, Assistant Professor in Pediatrics, Department of Woman’s and Child’s Health, University of Padova, Italy) on behalf of the study Authors.

Paediatric mortality remains high in developing countries but there is little data to inform public health and non-governmental organisations on the exact burden of disease or the causes for emergency attendance at hospitals. The authors of this study aimed to examine the epidemiology of paediatric urgent and emergent presentations in Nicaragua, with the goal of identifying modifiable factors to reduce childhood deaths in the country.

Data was collected from a registry, set up through collaboration between several stakeholders including the Ministry of Health, a non-profit organisation, a group of Italian paediatricians and local stakeholders. The registry covers 8 hospitals, 7 of which are community based and one of which is a large referral hospital in the capital city, although the data of one community hospital were eventually excluded from final analysis as logistic issues hampered data collection. Urgent and emergent attendances were identified over a one-year period between January and December 2017. In total, there were 3,441 visits of which 34% were by children less than one year. The main reasons for presentation were respiratory (46%), gastrointestinal (12%) and neurologic (11%) problems; in addition, 18% of children were malnourished. Overall mortality was 7%, with 32% of these children dying within 24 hours of initial assessment. The most common cause of immediate death was septic shock, with pneumonia and congenital heart disease being the most common causes of death overall. Risk factors for mortality on multivariate analysis were: age less than one year and above 12 years, malnutrition, co-morbidity or presentation with respiratory, cardiological or neurological complaints.

It is hoped that this information goes some way to describing the patterns of paediatric emergencies in Nicaragua and can be used by the government to plan and strategise how paediatric emergency care is delivered.

The Authors’ take home message

“Our project’s data on the patterns of paediatric emergencies and risk factors for mortality in Nicaragua is the first of its kind in this country and will help optimise distribution and use of resources, as well as plan the most appropriate feasible and effective interventions to improve paediatric emergency care at a local and national level.”

Contact Silvia about this work: [email protected] [email protected]

“Acute traumatic coagulopathy in childhood and high mobility group box 1” by Emel Ulusoy et al. (MD/ Dokuz Eylul University Faculty of Medicine, Department of Pediatric Emergency Care, Izmir, Turkey)

In recent years there has been an increasing focus on preventing coagulopathy in trauma patients. Acute traumatic coagulopathy (ATC) is an important cause of mortality in injured patients and although we know of several modifiable risk factors, predicting who will develop the condition is still difficult. Some adult studies have investigated the role of high mobility group box 1 (HMGB 1) proteins in the prediction of ATC; the authors of this study have examined its role in the paediatric trauma patient.

This prospective case-control study was conducted between August 2016 and May 2017. It enrolled 100 paediatric trauma patients: 67 were multiply injured and 33 had isolated head injuries of varying severity. Blood samples for HMGB 1 were collected from all patients and analysed using an enzyme-linked immunosorbent assay (ELISA). Results were compared to 50 healthy controls. Of the 100 trauma patients, 3 were deemed to have disseminated intravascular coagulation (DIC) and 35 to have ATC as per the International Society of Thrombosis and Haemostasis (ISTH) DIC score. Patients with ATC had higher levels of HMGB 1 than those without (1.84 and 1.47 ng/mL respectively), although the confidence intervals overlap. Levels were also higher in trauma patients than in controls (1.47 and 1.16 ng/mL respectively) and were associated with clinical outcomes such as days of mechanical ventilation, need for intensive care unit admission, length of hospital stay and mortality. These results are promising, potentially offering an early biomarker in the diagnosis of traumatic coagulopathy, although this will need validation in a larger cohort.

Emel’s take home message

“ATC has vital importance in paediatric trauma patients because it not only develops during trauma but also affects the course of the traumatic process. We need to find markers such as HMGB1 that will help to identify it earlier so that we can prevent it instead of treating it after it develops.”

Contact Emel about this work: [email protected]

“Hemispheric cerebral oximetry (rcSO2) readings in Status Epilepticus in a pediatric emergency department: relationship to seizure complexity, anticonvulsant therapy and possible prediction trends” by Thomas Abramo et al. (Pediatric Emergency Medicine Physician, FAAP, FACEP Professor of Pediatric and Emergency Medicine at the University of Arkansas School of Medical Science, and Arkansas Children’s Research Institute, Little Rock Arkansas USA).

The highly variable nature of paediatric seizure manifestation results in many paediatric seizures going unrecognised. Particularly challenging groups include intubated children and those with neurodevelopmental delay. For every first-line benzodiazepine minute delay (> 5-10 minutes) there is an increased risk of prolonged seizure (> 60 mins.), progressive diminished benzodiazepine efficacy and an increase in Status Epilepticus (SE) incidence and duration. This is a complex area within which the author has a wealth of experience; to fully capture the nature and depth of this problem, please see their other published work.

Research in epilepsy has found that both generalised and focal seizures cause abnormalities in cerebral oximetry (rcSO2) readings. Normal hemispheric rcSO2 readings in children are between 60-80%, with values outside of this or an interhemispheric discordance of >10% representing abnormal cerebral physiology. This study looked at whether rcSO2 readings in patients with seizures correlated to seizure duration and anticonvulsant use.

The observational study collected data on 101 neurologically normal, first-time seizure patients over a period of 4 years. The authors found that in general, seizure patients had rcSO2 readings of either <60% or >80%. Those with readings <60% had a longer seizure duration and required more anticonvulsants than those with readings >80%, especially if aged under 2 years. Readings returned to normal in the post-ictal period, with seizure readings >80% returning to baseline faster than those that were <60%. This evidence would support cerebral oximetry to help identify seizures in paediatric patients, as well as predict seizure duration and response to anticonvulsants. We look forward to seeing further work of this kind from the author in the near future.

Thomas’ take home message

“In paediatric seizures, incorporating cerebral oximetry as a standard-adjunct, from a neuroresuscitation perspective, would decrease: seizure-recognition failure, the time-to-initiation of anticonvulsant therapy and the subjectivity of neuroresuscitation. It would also improve the reliability of seizure assessments and provide objective consistency for both seizure identification and assessment of appropriate therapeutic response.”

Contact Thomas about this work: [email protected]