July 2018

Author: Andy Neill / Codes: CAP14, CAP18, HAP5, HMP4, PAP12, PAP8 / Published: 01/07/2018

Becky Maxwell
Chris Connolly

– Andy Neill
– Dave McCreary

Clinical Question
– which clinical decision rule (if any) should we use for head injuries in kids?

– Accuracy of clinician practice compared with three head injury decision rules in children: a prospective cohort study

– EM seems to love a good clinical decision rule (CDR). There are no shortage to choose from. In the UK are decision making for scanning is guided largely by NICE but even then many of us incorporate our own gestalt into scanning head injuries and likely scan less kids than the NICE guidelines might suggest. If anecdote is anything to go by I expect we do the opposite with the adults…
– There are a number of CDRs available and reasonably well studied internationally. This study aimed at comparing 3 CDRs with each other and with good old fashioned clinician gestalt in an area suspected to have low scanning rates – in this case Aus/NZ

– this is a planned sub study of a prior paper that investigated the 3 CDRs
– Aus/NZ considered a low scanning area, yet they still are part of the PECARN research network
– looking for clinically important brain injury (which is nice in some ways but i still would like to know if there was any injury there!!)
– got enrolled if you were a kid with a mild head injury (GCS 13-15)
– lots of data got collected and this was all before a decision was made on whether to get a CT. Whether or not you got a CT was down to the doc loking after you.)
– (first caveat – it’s hard to see how that clinician decision is not affected by the rules, it’s like the PE thing all over again. These things are so ubiquitous that they literally are part of our gestalt)
– telephone follow up for those who didn’t get CT at first visit

– 20000 kids
– 9% CT rate, 0.1% (24 kids) underwent neurosurgery. That neurosuregry rate is staggeringly low. Use that in your next parental counselling over why you’re not getting that CT.
– of those scanned 10% had important brain injury (which seems high enough and is likely spot on where you want to be)
– the clinicians “missed” 2 of the brain injuries (they scanned 158/160 of them on first visit) so they had excellent sens and spec)
– both cases were a bit weird and were totally acceptable “misses”. neither required surgery
– clinician accuracy (sens 98.8, spec 92.4) was better than all of the rules apart from PECARN (which had slightly better sensitivity but much worse specificity)

Bottom Line
– if you were trained in Aus/NZ then a decision rule for head injury in kids is not going to help you. keep doing what you’re doing. If you’re in the UK or Ireland then I suspect similar things.

Nikki Abela
Sarah Stibbars

This talk was recorded at the RCEM Spring CPD event in Cardiff in 2018

Charlotte Davies

Pituitary Apoplexy
Acute haemorrhagic or non-haemorrhagic necrosis of the pituitary gland. An existing pituitary macroadenoma is usually present (60-90%) but it can occur with healthy glands in few isolated cases. It is also more likely with medical treatment of a prolactinoma, pregnancy (Sheehan) and cerebral angiography, trauma and sudden changes in ICP.
As the gland suddenly enlarges it may cause compression of structures adjacent to the sella leading to:
sudden headache
loss of visual acuity with a chiasmal field defect
oculomotor palsies (CN III)
Decreased level of consciousness, hypopituitanism, Addisonian crisis and subarachnoid irritation.

CT – routine CT is insensitive to the diagnosis unless frank intracranial haemorrhage is present. The pituitary mass may be evident and be hyperdense. Fluid debris levels may also be evident. Useful to do to exclude a sub-arachnoid.

MRI – typically demonstrates a pituitary region mass. Confirms the diagnosis in over 90% of patients. A pituitary CT is indicated if MRI is contraindicated or not possible.

Endocrine evaluation with blood samples for random serum cortisol, TSH, free T4, prolactin, IGF1, LH, FSH, testosterone (men), oestradiol (women) for later analysis
Hyponatraemia in 40% of cases

Hydrocortisone 100 mg i.m. bolus followed by 50–100 mg six hourly by intramuscular injection or 100–200 mg as an intravenous bolus followed by 2–4 mg per hour by continuous i.v. infusion can be used

Neurosurgical intervention should be considered in patients with:
Severely reduced visual acuity
Severe and persistent visual field defects
Deteriorating level of consciousness


Addisonian crisis guidance


Mark Winstanley
Danni Hall

This talk was recorded at the RCEM Spring CPD event in Cardiff in 2018

Paper Referneces:

Foster, Cooper, Oosterhof and Borland. Oral prednisolone in preschool children with virus-associated wheeze: a prospective, randomised, double-blind, placebo-controlled trial. The Lancest Respiratory Medicine 2018. 6(2): 97-106

Cronin et al. A randomized trial of single-dose oral dexamethasone versus multidose prednisolone for acute exacerbations of asthma in children who attend the emergency department. Annals of Emergency Medicine 2016. 67(5): 593

Paniagua et al. Randomized trial of dexamethasone versus prednisolone for children with acute asthma exacerbations. J Pediatr. 2017. 191:190-196

McCrindle et al. Diagnosis, treatment and long-term management of Kawasaki disease: a scientific statement for health professionals from the American heart association. Circulation 2017. 135(17)

Bhatt et al. Risk factors for adverse events in emergency department procedural sedation for children. JAMA Pediatr 2017. 171(1):957-964

Vassallo et al. Paediatric traumatic cardiac arrest – the development of a treatment algorithm. EMJ 2017. 34(12)

Eoghan Colgan
Gerry McGarry

This segment first appeared on the St Mungoes podcast ion June 2018 and is used here with permission.

For more on St Mungos check out stmungos-ed.com

Dave McCreary
Andy Neill

Clinical Question:
How reliable is isolated vomiting for predicting intracranial badness is kids who’ve bumped their heads?

Title of Paper:
Association of Traumatic Brain Injuries with Vomiting in Children with Blunt Head Trauma

Journal and Year:
Annals of EM. June 2014

Lead Author:
Peter Dayan

Kids bump their heads often Kids vomit, also often
Some kids who bump their heads also vomit Radiation is probably bad for young brains
Most head injury decision tools include vomiting in their criteria for scanning Could it be safe just to observe them for other signs of deterioration rather than going straight to scan?

Patients Studied:
Kids ( * Excluded patients who ran into stationary objects (every toddler that ever toddled), and ground level falls with no evidence of TBI
Study Design:
Planned secondary analysis of PECARN dataset

Clinicians documented standardised history and physical examination on a case report form prior to CT (if done) Evaluated presence or absence of vomiting any time after injury up to ED evaluation
Number of vomiting episodes, timing of onset, time since last vomit. Defined isolated vomiting in two camps:
Extensive – Just vomit, and no other symptoms from an extensive list commonly associated with TBI PECARN list – divided between

1. Clinically important TBI (ciTBI)
Death, neurosurgical procedure, intubation ≥24hours, hospitalisation ≥2 nights
2. Traumatic Brain Injury on CT Any acute traumatic intracranial finding or skull fracture depressed by at least the width of the skull

Summary of Results:
43,904 patients enrolled in the parent study 5392 patients included (vomiters post exclusions)
815 (15%) had isolated vomiting 298 (36.6%) got scanned

ciTBI found in 2/815 (0.2%) patients with isolated vomiting (any time, any number of episodes)
vs 114/4577 (2.5%) in the non-isolated vomiting group
Both patient had a ≥2night admission in association with TBI on CT, nil had neurosurgical intervention or died
TBI on CT in 5/298 (1.7%) of isolated vomiters who were scanned
0.04% (3/6936) of overall cohort had ciTBI without vomiting or any other defined finding

Authors Conclusion:

TBI on CT in uncommon and ciTBI is very uncommon is children with minor blunt head trauma which vomiting is their only sign or symptoms, assessed at a single point in the ED. Consequently, CT is generally not required in these children those a period of clinical observation in the ED before CT decision making is prudent to assess for progression of signs or symptoms. TBI is more frequent in children when vomiting is accompanied by other signs or symptoms suggestive of TBI and so CT should be seriously considered in these circumstances.

Clinical Bottom Line:
I really do think if your own clinical suspicion is low, and other than vomiting the kid looks and examines otherwise well I wouldn’t (and don’t) rush into CT. There is very much room for sensible discussions with the parents to decide the best course of action. At a minimum I like to observe them and usually admit them overnight for this.

References for radiation and cognitive development
ncbi.nlm.nih.gov PMC4219853
ncbi.nlm.nih.gov PMC313898

Becky Maxwell
Chris Connolly

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