Authors: Liz Herrieven / Editor: Nikki Abela / Codes: SLO5 / Published: 11/01/2022
*Not quite the whole of PEM, but I’ve tried my best
I was very pleased to be asked to speak at the EMTA 21 virtual conference, until I realised my brief was to cover SLO5 in 30 minutes.
A bit of a challenge. So I did what every self-respecting EM physician does when they’re unsure what to do, I asked for help. The good people of MedTwitter didn’t let me down. Here are the PEM Top Tips I managed to collect: some of them mine, many borrowed. Hopefully one or two of them will help you (and your patients) out.
What do you need to know before you even step foot near the PED?
Wear comfy, washable shoes. You’ll be on your feet a lot and you’re guaranteed to get covered in all manner of bodily fluids, not to mention liquid paracetamol – the stickiest substance known to mankind.
Inside those comfy, washable shoes, wear funny socks – always a good talking point when you’re trying to win over a small child.
Know your TV characters. Make sure you can distinguish Cocomelon from Bluey, and Peppa from Duggie. Knowing at least two of the Paw Patrollers can give you bonus points. For older kids, it’s worth learning a bit about Premier League football teams and making sure you can name a couple of players. Nursery rhymes are essential learning and you have to be able to sing at least two verses of Baby Shark.
Listen to the nurses. You may be an experienced PEM doctor or setting foot in the PED for the first time, but that rule still applies. The nursing staff know their department and they know children. If they are worried, you should be too.
If you’re thinking of asking for help, then do. Nobody knows everything and even us old-timers still ask for help on occasion.
Nobody wants to be in the ED. Particularly patients and their families. Don’t ever berate anyone for coming. The family in front of you have come because they feel that whatever is happening to them is an emergency. They may have had to drop other children off at a relative’s house, plan out a bus journey, pay for a taxi or search for a parking space. They’ll have probably packed a bag of things to tide them over whilst they’re waiting. All because they feel their problem is serious. Listen to their concerns. If needs be, make it a teachable moment, but don’t ever tell them off.
Leave on time. It’s a marathon, not a sprint and decision making is so much harder when you’re tired (Ed: EM is a relay, when your part is over, you need to hand-over to be well enough to start again when your time comes).
Don’t ever lie to children. They will never trust you (or any other health professional) again if you tell them something won’t hurt, when it does.
Give children choices. Pre-schoolers in particular like to be in control. Ask them which ear you should look in first (you’re going to look in both) or which bandage they’d like you to use (they’re both identical bandages). You get a compliant child and they think they’re the boss.
If you are looking to read more, here are some sites to get you going:
Kids Are Not Little Adults
Children have particular anatomical and physiological differences which make them their own little species. The smaller they are, the more alien they are to adults. Let’s look at their ABCD as an example:
Airway: children’s airways are shorter, narrower, higher and more anterior than adult’s airways, so more likely to obstruct. They are also funnel shaped, as opposed to the cylindrical adult airway, making them more prone to occlusion by a foreign body. Babies need a neutral airway position (face horizontal, eyes looking up at the ceiling). Their big occiput may require you to extend the head on the neck slightly. Older children need that sniffing-the-morning-air position, the same as adults.
Breathing: small children are rubbish at breathing. Not only do babies only really know how to breathe through their noses, creating all sorts of problems when they get snotty, but small children have really weak chest wall muscles. When they try to expand their chest to create a more negative intra-thoracic pressure and suck more oxygen in through their airway, it doesn’t work. Instead they suck bits of their chest wall in, which we can see as recessions. Adults may try to splint their chest by leaning on their arms, and use their shoulder girdle to expand their upper chest and improve their respiration. When babies do this they fail dismally and their sternomastoid ends up just making their head bob up and down instead. The diaphragm is the main muscle of respiration for little ones. It works pretty well until a distended stomach (milk, air, etc) stops it moving. A great tip for helping with respiration is to insert an NG tube and empty the stomach, to stop it splinting the diaphragm.
Circulation: children can maintain a blood pressure that perfuses vital organs through compensatory mechanisms until the very last moment. One of these mechanisms involves increasing their cardiac output by increasing their heart rate. So a tachycardia can be a great clue that a child is sick. Unfortunately, a tachycardia can also be caused by fever, pain, anxiety and running around the playroom before being called into a cubicle. Another compensatory mechanism is the increase in systemic vascular resistance, diverting blood from the peripheries to the major internal organs. We see this as mottling, a corned beefy appearance to the limbs, cool hands and feet and delayed capillary refill.
Disability: sick children may be quiet, withdrawn or lethargic, amongst many other things, but children in the ED may also be anxious, shy, scared or just a little excited. You’ll only really know if the behaviour you’re seeing is appropriate if you ask the parent how their child would usually behave in a strange place with strange people.
So yes, kids are not little adults.
Although sometimes, kids CAN be little adults. When your mind goes blank remember that the first 5 letters of the alphabet are still the same, ABCDE, and that the most important thing, no matter the age, is that oxygen goes in and that blood goes round and round.
We found that the term “kids are not little adults”, can sometimes strike fear into us, especially when dealing with trauma. If you want to read more about this, go here: RCEMLearning Paediatric Trauma Anatomy.
Use Your Powers of Observation
In PEM it’s vital to use your powers of observation. Trust what you see. There may be a vague history involving lethargy and poor feeding, but if the child in front of you is bright and drinking, believe it. There may be uncertainty over a possible loss of consciousness after a bump to the head, but if the child is alert and active and playing, believe it. Most children, when seriously ill, get worse and worse, they don’t fluctuate.
Watch the child in the waiting room before you call them in. Their activity and behaviour will tell you a lot. If they have to be pulled away from the play equipment they are probably ok.
Watch for the Quaver-positive sign (other snacks are available) and the Text-positive sign. A child munching their way through a bag of crisps or checking out Youtube (is that what the kids use nowadays?) is probably ok. Use this sign along with your other clinical signs, though, not in isolation, and put everything in context.
Watch the child walk through from the waiting room or climb onto the examination trolley. How do they use their injured limb? The child hopping through with an ankle injury is less likely to have a break than the one tentatively trying to put their foot to the ground, wincing in pain and leaning on their parent. Every time you hop or jump, jerking that ankle about is painful. Children with appendicitis will usually be in pain when walking and will struggle to climb on to the trolley. The child who runs in and bounces around is more likely to be ok.
Observation is an investigation.
If the child is not fighting the cannula or oxygen mask they are probably far sicker than you think they are. Remember to use your eyes and ears in the paediatric ED.
If you haven’t ever heard of or used the Paediatric Assessment Triangle, there is an excellent blog on it here from DFTB.
How can you get a child to cooperate with your exam-standard clinical examination? Well, you probably can’t, to be honest, but there’s lots you can do to pull out those clinical findings.
You’ll only have about 2 seconds to win the child over, so find something to compliment them on, and quickly! Tell them you like their t-shirt, shoes, toy, (whatever) but don’t ever try to take that toy off of them! Speaking of toys, it can help to “examine” the toy or even the parent before examining the child, to let them know what’s going to happen.
Distraction is great: some tips are already mentioned above, but others include screens or bubbles. If a child is properly distracted you’ll be able to properly palpate that arm/leg/abdomen, watching their face for pain. It’s often not worth asking a small child if something hurts as they’ll usually tell you what they think you want to hear rather than the truth. Their face won’t lie though. Bubbles are also fab diagnostic tools. Get the child to point at bubbles, pop them or clap them and you’ll be able to see how they use (or don’t use) their injured limb (and coordination).
Make your examination into a game. Can you guess what food is in their belly just by palpating? Can the parent see the light you shine in one ear coming out of the other? Can the child blow out the light at the end of your pen torch? Can the child copy some silly faces? Even high-fiving tells you a lot about their GCS, coordination, power, tone…
If you must look in a child’s ears and throat (and you don’t often need to) then position is everything. For ears, have the child sat sideways on their parent’s lap, with one of the parent’s arms around the child’s arms, and the other on the forehead to keep them still. For throats, have the child sat up, on their parent’s lap, facing you. Again one of the parent’s arms should be around the child’s arms and chest, and the parent’s other hand should be on the child’s forehead. Take your tongue depressor and rest the tip on the child’s bottom lip. Gradually edge it forwards, over the lip, onto the teeth and then onto the tongue. When you’re on the tongue, press down and the child will gag, giving you a beautiful, but brief, glimpse of their throat. Be prepared to jump out of the way if they vomit and never kneel in front of them to do this!! Another tip is to ask the child (if they’re old enough) to try to lick their chin – that should give you a great view, without the gag.
Don’t forget stickers – great for bribery and for rewarding a cooperative child, but also something to make the child start to forget anything nasty you may have had to do.
Not strictly examination, but something that will definitely help your assessment is listening to the parents. Always listen to the parents, they know their child best and will know when something isn’t right. But also, keep an open mind – what are they not telling you? Take your time and listen. Edward Snelson gives us some great tips here.
Never trust a neonate. They are slippery little things. Have a low threshold for asking for help or advice.
Take feeding, for example. A baby with “reduced feeding” may have been over fed and so not finishing feeds, may have a viral URTI, or bronchiolitis, or sepsis, or a UTI, or meningitis, or a metabolic condition, or a congenital bowel anomaly, or a cardiac anomaly, or raised intracranial pressure after being shaken…. Literally anything is possible, so never trust them!
Remember the neonatal sepsis risks: were they born before 37 weeks? Did the mother’s waters break more than 18 hours before delivery? Did mother or baby have a fever? Was there meconium staining of the liquor? Did the mother have a UTI, group B strep or chorioamnionitis?
Fever is important in a neonate (probably one of the few times it is important). A temperature of 38C or more in a baby under 3 months is a red flag, as is a temperature of 39 or more in a baby aged 3-6 months.
Handle the baby. Pick them up, help get them undressed. This will tell you lots about their tone and responsiveness. Palpate the liver and the femorals in every baby you examine. These are not easy to feel and one day being able to tell that the femorals are weak or absent or that the liver is enlarged might help you diagnose a cardiac condition. Get used to how normal feels.
Talking of normal, it’s worth knowing about the kinds of things which are normal for babies but very distressing for parents – crying, feeding issues and rashes in particular. Get started here and here: the unwell neonate and here.
Children with additional needs
Assessing a child with additional needs, whether that be a learning disability, autism, a communication delay or a physical disability, can be challenging for the clinician, the child and the parent.
Remember the TEACH mnemonic:
Time: you may need to take a little extra time assessing these children, but that time is a very worthwhile investment.
Environment: can you find somewhere quieter and less distressing for the child to wait to be seen? Can you remove some of the scary equipment from the room?
Attitude: have an open mind, assume nothing about quality of life and watch out for diagnostic overshadowing (when any new symptoms are put down to a pre-existing diagnosis).
Communication: absolutely vital. Find out how to make yourself understood, as well as trying your best to understand your patient, including thinking about non-verbal communication. Could symbols or signs help you? Pictures, photos or even pointing at body parts or equipment?
Help: what help does your patient need? What help do you need? Could a hospital passport give you some clues? Is there a care plan available? What information can the parents give you? Are you lucky enough to have a learning disability nurse to call?
This deserves a whole section to itself as there’s a huge amount of fever fear, both amongst health professionals and parents.
It’s ok to have a fever (unless that child is under 6 months of age: see neonates section). It’s ok to discharge a child that has a fever. Don’t worry about the fever. Worry about the child. If the child is tolerating the fever ok, there is no need to give antipyretics.
If you do give antipyretics, make sure you explain to the child’s parents why you’re doing it. For example, you may want to see that a tachycardia settles when the fever starts to settle. If you don’t make it clear that you’re not concerned with the fever itself, then they will return later when the fever returns.
If there is a clear source for the fever, then that is the source for the fever. There is no need to screen any particular bodily fluids (I’m looking at you, urine) if the child has a fever, cough, runny nose, etc (except for neonates, never trust them).
Investigations are rarely useful in the paediatric ED, particularly blood tests. Before you request an investigation, ask yourself what your pre-test probability is and what you’ll do with the result, whether positive or negative. Will the investigation change what you do?
Blood tests are a big deal for children, parents and the person who has to take the sample. What you do now will have an impact on any future interactions the child will have with healthcare professionals. If you simply must take bloods, then limit your attempts and be prepared to seek help if you’re not successful. Position and preparation are key. Take your time and take a nurse and ideally a play specialist with you. Consider using topical local anaesthetic creams or Elsa’s Frozen spray (ethyl chloride). For some children, they might like the idea that their cannula is actually a Spider-Man web slinger.
When thinking about x-rays or CT scans remember to stick to the ALARA principle and keep radiation doses as low as reasonably achievable. We don’t often do “trauma scans” (CT of the whole body) in children, so check out the guidance, and not many children with breathing difficulties need a chest x-ray.
Some excellent resources are: WILTW blood tests and paediatric trauma imaging and ECGs in children.
Spotting the well child is as important as spotting the sick child. Normal physiology is reassuring, as is normal behaviour. If you’re unsure if the behaviour is normal for the child, ask their parent.
Trust your gut. This is nothing about your bowels and everything to do with pattern recognition. If something doesn’t feel right, there’s probably a reason for it.
Remember that bronchospasm isn’t the only cause of wheeze. That noise just signifies turbulent flow through a narrowed passage, which may be due to oedema and mucus (bronchiolitis for example), a foreign body or, yes, bronchospasm.
A great tip from Twitter: always consider button battery ingestion in children with abdominal signs and symptoms and no identified cause.
Treat the child, not the fever.
Treat the child, not the wheeze.
In fact, just treat the child.
Antibiotics are not the safe option – they taste vile, the course is often not completed (you try making a toddler take a foul-tasting medication 4 times a day for 10 days), they give children diarrhoea and inappropriate use builds resistance.
Not everyone needs a fluid trial. And by that I mean a formal fluid trial with the parent giving 1ml/Kg of oral fluid every 10 minutes by syringe. Think about what you’ll do after the fluid trial. If the child is going home either way, they don’t need the fluid trial. If the child is getting intravenous or nasogastric fluid either way, they don’t need the fluid trial.
If the child is happily drinking from a cup or bottle or breast, let them.
The three Ds are great: Difflam (sore throats and not drinking), Dioralyte (gastroenteritis) and Dexamethasone (croup). In fact, according to MedTwitter, Difflam is Magical. (Ed: I agree. Also, try the A for gastroenteritis: Apple Juice: at half strength, of course).
If you’re lucky enough to have a freezer in your department, ice lollies are great for rehydration. (If you don’t have a freezer: how about a QIP?).
We’re moving towards minimal treatment in so many areas of PEM – consider the CAP-IT study and the use of low dose, short course antibiotics in community acquired pneumonia, or the FORCE study looking at the use of a soft bandage for buckle fractures or the CRAFFT study looking at conservative management of displaced forearm fractures.
Congratulate parents on the job they’ve done before coming to the ED, whether that be giving analgesia, working on oral hydration or watching out for red flags. Build on this when you give advice about how to continue caring for their child.
When discharging a child, make sure you properly “safety net”. Don’t just say “bring them back if they get worse”, but be specific. Explain exactly what the parents should look out for and what they should do about it. Give them permission to come back, if they need to. That way, they’ll feel empowered to continue to care for their child at home, knowing they have a back up plan.
I can’t possibly include absolutely every condition you’re likely to come across but, hopefully, these tips will get you through the average PEM shift. There’s lots of PEM content on RCEMLearning – and most of it is even mapped to SLO5!
Oh, forgot one… Enjoy!! Working with kids can actually be great fun, even when it’s crazy busy and everyone is full of snot.
Huge thank you to everyone who contributed to these PEM Top Tips:
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