Authors: Nikki Abela, Liz Herrieven / Editor: Nikki Abela, Liz Herrieven / Codes: EnP3, OptP2, SLO5, TC4, XC1 / Published: 18/04/2023

​​Nikki Abela and Liz Herrieven have treated themselves to the RCEM PEM Conference in Manchester on 21/3/2023 – World Down Syndrome Day. Put on your #LotsOfSocks for the day and have a read to see what they learned.

The day opened with a talk on major incidents by Dr Rachel Jenner. As many of you know, Manchester was the home of the concert blast 6 years ago and so the team have real-life experience to share with us.

A Major Incident is defined as:

 Any occurrence that presents a serious threat to the health of the community or causes such numbers or types of casualties, as to require special arrangements to be implemented.

A major incident preparation may also be known as EPRR – emergency preparedness, resilience and response.

The truth is we don’t know when or where they are going to happen. Sometimes there is a sequence of events which may hint at the possibility but generally there isn’t. Statistically though, everyone who works in our job will be involved at least once in their lifetime.

Not all are trauma, some are medical, for example, mass food poisonings or carbon monoxide leaks. Some major incidents are “chronic” – the COVID-19 pandemic ticked all the boxes, but was slow to start, involved several waves and needed different planning and management compared to the shorter, sharper major incidents which result from explosions or terrorist attacks. 

All hospitals will have a major incident plan. Do read it. Not during the incident itself. In the plan there will be action cards – you do need to read the card for the role you will be doing at the time of the incident.

The METHANE structure may only give you limited information, you may need to accept that it will evolve with time. Our specialty is great at developing plans and adapting on the go, so acknowledge that things may change and go with it.

The priority of patients will also change. The pre-hospital triage* “sieve” will sort patients into:

P1 – immediate
P2 – delayed
P3 – minors
P4 – expectant (dead or obviously dying aka P1 Hold) – unless you work in pre-hospital realistically it won’t be something you need to deal with.

Patients are then re-triaged when they arrive at hospital (triage “sort”), but things can change, necessitating re-triage. 

Other things to consider: 

  • You will need not only extra staff but also extra psychological support (could you call CAMHs?) – they found this really useful in the Manchester bombing.
  • A radiation sparing approach may not be appropriate in a major incident – quicker and more efficient to CT patients as if they were adults. 
  • Blood borne virus prophylaxis and infection control in blast injuries (especially if shrapnel or projectiles are involved which may have injured several people) or in incidents involving one blade and lots of victims.
  • Flow will need to be unidirectional (e.g. from resus to CT to theatre/ward/ICU without going back to resus).
  • Admit families side by side. How will you manage parents alongside children in an incident involving a range of ages/people?
  • Children do not carry identification on them so make sure you have MAJAX numbers
  • You may not know the age of your patient – go with an estimate based on size and appearance. If they turn out to be 18 instead of 14 later on, that can be sorted out when you get time.
  • Self-presenters don’t read the MAJAX plan. They’ll turn up when they want, where they want
  • Where will you discharge patients to? Do you have a plan for what to do if their parents are still being treated? Or can’t be found?
  • Where will food and drink come from, for staff as well as patients?

Be aware that you will have an acute stress reaction after being involved in a MAJAX – even the ones who didn’t come in may feel stressed, guilty or undervalued – that is normal.

The first stage of the aftermath is a press response, with high-profile people visiting the department then, much later, there is an inquiry, which is extremely stressful and may again be high-profile. Psychological support is invaluable.

Things to read:

*Major incident triage is changing soon – watch out for the new NHS Major Incident Triage Tool, MITT, which will involve less maths and physiology and will triage all children under 2 years of age as P1. How will that affect EPRR planning in your hospital or department?

Professor Damian Roland came next and talked about how practice has changed since he started medicine and how evidence has changed our practice. For example, do you still bring buckle fractures back for review? Do you use Airvo for bronchiolitis induced hypoxia?

Practice is variable – not just across time but between clinicians and departments…and it’s difficult to change. Even with good evidence for change, that change can take a huge amount of time to filter through to the shop-floor. 

We do have to keep up with new evidence though, especially with a 30% increase in paediatric ED attendances since pre-pandemic. The NHS Plan predicts an increase of 50% by 2030. 

Frequent attenders form up to 10% of our workload in paediatric emergency medicine. Those most likely to attend more often are under the age of 1 year, male, from a deprived background and from an Asian or mixed ethnic group. 

What can we do to help this group, to reduce re-attendances and manage the increase in workload generally? Data is easy to come-by, but doing something about it is harder. 

One small thing we can do, highlighted by the CAP-IT study, is explain to parents that children will have a cough for several weeks after a chest infection (whether bacterial or viral) as a part of the inflammatory response, rather than acute infection.  They don’t need to re-attend purely for continued cough. 

Of course, Damian is part of PERUKI which brings together clinicians who want to change emergency care for children through research – if you want to get involved, register through the website and look for the PERUKI lead in your trust.

In the POCUS session, Dr Peter Hulme talked about how POCUS can change our practice. It is different in children, compared to adults, but it can be used to reduce radiation risk. It is, of course, something you need to learn and the process for this is still evolving, but with time may be something we use more to add a piece to our diagnostic puzzle in paediatrics.

Fay Challender gave us some great tips for reviewing paediatric x-rays. For example, the scaphoid bone isn’t ossified until age 10/11 years, so doesn’t fracture until at least that age. After age 10, if there are clinical signs of scaphoid fracture, aim to re-image at 7 to 10 days (plain film is usually fine). Don’t forget, the anatomical snuff box will also be tender if the distal radius is fractured. 

When it comes to children’s bones, the physis is the weak spot, so this is where you need to check first. The epiphysis should sit on the metaphysis like ice-cream on a cone. If they don’t align, consider a Salter-Harris fracture. 

For clavicle fractures (if your department is imaging them and not treating clinically), if you suspect a fracture but can’t see one, look at the inferior cortex – is there a subtle step?

When reviewing ankle images, always look at the base of the fifth metatarsal, too, which should be clearly visible. Don’t forget to look through the talus on the lateral view at the malleoli. 

Triplanar and Tillaux fractures are common in adolescents, as the physis starts to fuse from the middle outwards. A triplanar fracture is a complex, unstable Salter Harris 4 fracture of the ankle. 

Seymour fractures are Salter Harris type 2 fractures of the distal phalanges, for example after trapping a finger in a door. If the nail bed is involved, these are open fractures. 

Think about the mechanism of injury when reviewing images and this will help you to know what you’re looking for. Landing heavily or awkwardly on one leg on the trampoline is a bit like a FOOSH – there may be a buckle fracture of the proximal tibia, just like a FOOSH gives a buckle fracture of the radius. 

Dr Rutika Dodeja gave us some great tips for assessing and managing eye problems in the paediatric ED:

  • To assess for proptosis, look from above
  • Funky pens can be great fixation targets when examining young children
  • Open globe injuries: put a shield on, CT for foreign body and call ophthalmology
  • Orbital fractures: call ENT, give antibiotics and don’t let them blow their nose!
  • Dendritic ulcers: proxymetacaine, swab (to debride the ulcer and confirm the organism) and give ganciclovir
  • Foreign body: soak a cotton bud in proxymetacaine before using it to remove the foreign body (using a needle and slit lamp is more tricky in children, especially if they’re a moving target)
  • Chemical injuries: irrigate, irrigate, irrigate. Don’t chase the pH. If you’ve irrigated with 2 litres of 0.9% saline and fluorescein shows no epithelial defect you can discharge. If there is a defect – call ophthalmology
  • Monocular double vision does not exist
  • Emergencies which require ophthalmology NOW: chemical (especially alkali) injury, ruptured globe, retrobulbar haemorrhage
  • Retrobulbar haemorrhage far less common in children and usually associated with an orbital floor fracture, which provides a route for decompression, making lateral canthotomy less often required 
  • Blurred disc margins? Often sent to ED by opticians. If no neurology, no need for scan. If you’re not clear about the disc margins, get ophthalmology to see (all puns intended).

More great tips here.

Dr Bernd Schwahn spoke about metabolic emergencies. For adults, this means diabetes, intoxication or other acquired metabolic disease. For children, it’s more often something genetic. If they come to the ED, it’s usually because they’re either decompensated, or in danger or imminent decompensation. If they have a care plan, follow it. If they’re acutely unwell, the clinical picture can get very confusing and complicated – anything goes. Acute metabolic decompensation can present with reduced GCS, seizures, hyperventilation, respiratory distress or stroke. 

An accumulation of organic acids and osmotic diuresis causes a metabolic acidosis, with hyperventilation (to blow off CO2), lethargy and signs of dehydration. 

A raised anion gap could be because of ketoacidosis, lactic acidosis or both. 

Ketoacidosis can be caused by starvation, ketogenic diet (e.g. for some complex conditions), organic acidaemias, DKA, exogenous intoxication (alcohol most often) or disorders of ketone body utilisation. 

Lactic acidosis isn’t just sepsis! It arises due to a mismatch between intracellular glucose supply and the capacity for oxidative phosphorylation. That mismatch might be a primary metabolic problem, or an oxygen/perfusion mismatch due to anaerobic exercise, oxygen deprivation or a perfusion problem (including shock).

To manage metabolic acidosis:

  • Fluid bolus
  • Rehydration
  • Provide energy (glucose)
  • Add potassium once diuresis confirmed (i.e. they’re passing urine)
  • Metabolic screen

For bicarbonate corrections, there are some fancy, complex formulae, but 2mmol/Kg works pragmatically.

In hypoglycaemia, collect the first urine after the hypo episode (apart from the hypo screen) – check it for ketones and save the rest (frozen storage if you can) for organic acid analysis. 

Hyperammonaemia? You won’t find it unless you look for it. Get your sample to the lab quickly. This can present with nausea, vomiting, ataxia, lethargy, behavioural change, abnormal movements, seizure or coma. 

If a child has an inborn error of metabolism, act quickly, even if they look well. Rehydrate, correct any electrolyte imbalance and provide energy: their care plan will tell you how to do this, if they have a pre-existing diagnosis. 

BIMDG has some great emergency guidelines, as well as guides to help make up infusions. We also have a great blog here.

The day also featured sessions on trauma informed care and spotting the child with malignancy – wish we could have seen everything!

Professor Simon Carley rounded off the day with a really thought-provoking session on decision-making and risk. Evidence-based medicine is important (if you’re still reading, Damian!) but that information has to go through the clinician. Do you believe it? Can you do it? How do you feel it relates to your patient/department/problem? What myths, opinions or beliefs do you weigh it against? It can take 10-14 years to get good quality evidence from trial to patient. 

In the ED we often see patients in the early stages of disease, when diagnosis is more difficult and investigations less helpful. Emergency clinicians are often judged on what becomes more obvious later on. Because of this, we often over-treat. Sometimes, despite making the right decisions, the outcome is bad. And vice-versa. 

The more experienced we become, the busier we get, the higher the pressure, the more we turn to type one thinking – i.e. pattern recognition and experience, with fast decisions. This carries a risk of missing things. 

Think about how you make your decisions, rather than focusing on the outcome. That might just give you your best shot at becoming your best self, work-wise. And remember that emergency clinicians are great at bringing together other specialties and leading a team. You don’t have to know everything, but you do have to know how to weigh up risk and coordinate response. 

Thank you to everyone who worked hard to put together a great PEM conference for 2023. We had a great day and hopefully you’ve learned something now too.