Coming via Zoom, PEMSoC was brought to us this time by the team in Southampton. Due to the pandemic and social distancing measures it was decided that switching to a virtual format could be exactly the way forward, and I think the day ran relatively smoothly!
We started the day with an adolescent emergency medicine update: Best not to forget their HEEADSSS – which is usefully available as an app which helps signpost to various resources and help in their area. In the UK we are doing well with reduced alcohol and tobacco use as well as a fall in teenage pregnancy. Drug use on the other hand is a bit of a grey area! One thing we have really found helpful was having a youth worker (having access to No Limits: https://nolimitshelp.org.uk/) and this seemed to resonate with the delegates who were keen to get in on the action in their local units too.
- https://www.paediatricpearls.co.uk/headsss-tool/
- https://play.google.com/store/apps/details?id=com.heeadsss.heeadsssApp&hl=en_GB
- https://apps.apple.com/us/app/heeadsss/id1418543003
Next up were some helpful nuggets on metabolic emergencies – something which we might not always have at the top of our differentials! Thinking about hyperammonaemia and hypoglycaemia. Don’t dismiss if ammonia is high, especially if >200! Think metabolic if >100, but REALLY THINK METABOLIC if >200.
Useful resources include the BIMDG website: http://www.bimdg.org.uk/site/index.asp and the eVM (vademecum metabolicum) app: https://apps.apple.com/gb/app/evm-vademecum-metabolicum/id1123172322 (sadly not yet available as an app on Android).
I will leave you with the speaker’s top tips:
- Stop feeds and start 10% dextrose (almost always)
- Involve specialist centre early on when suspecting metabolic disease
- Use BIMDG website
- Early recognition and appropriate management saves lives and reduces long-term morbidity
Next up was the diabetes update. Some of the issues raised included vomiting in a child with diabetes – always DKA until proven otherwise. Could this be newly diagnosed diabetes (with mid-range glucose e.g. 8.9mmol/L)? Give them some carbohydrates and re-check blood sugar (>11.1mmol/L = diabetes) and if glucose in urine, likely blood glucose >12mmol/L.
Fluid resuscitation may be the cause of a persisting acidosis in DKA, as typically chlorine loaded. To allow for this you can use the formula Na-Cl-32 (more info here: https://www.evelinalondon.nhs.uk/resources/our-services/hospital/south-thames-retrieval-service/Acid-base-interpretation-2017.pdf)
Questions to ask if unwell and a parent calls for advice: age, blood glucose, blood ketones (if young child or blood sugar >14mmol/L) what insulin do they usually take, and what have they had in the last few hours?
Looking at the differences in the new BSPED DKA guidelines:
- https://www.bsped.org.uk/clinical-resources/guidelines/ (here you can find the full guideline and an integrated care pathway)
- DKA calculator here: https://www.dka-calculator.co.uk/
Competence and capacity are always confusing subjects, especially in our adolescent patients and those aged 16 & 17 years. Discussion around use of the Mental Capacity Act and various questions from the audience came up – including use of rapid tranquilisation in paediatric emergency medicine when worries arise that the young person will hurt themselves, you or the team. Ensure the response is necessary, proportionate and the least restrictive option. The PIER network has guidelines specifically for rapid tranquilisation and you can find these on their website.
A paper was also shared and you can also find a podcast from Mr Wheeler in the links below:
- https://ep.bmj.com/content/98/1/26.short (relating to a case of 16y refusing treatment for paracetamol overdose)
- https://www.uhs.nhs.uk/HealthProfessionals/Clinical-law-updates/Children-refusing-treatment.aspx
More head-spinning info next about ‘Best Interests’ and medical ethics. Lots of questions! Do we need to move towards avoiding ‘Significant Harm’ instead? How do we actually define these terms? Do we use ‘best interests’ more colloquially and when it suits us? Could avoiding significant harm become more black and white for decision making in difficult circumstances?
- Check out The Transparency Project http://www.transparencyproject.org.uk/ for more information and resources relating to medical ethics and family justice
After lunch Stabilisation of the sick child was on the agenda. Case-based to illustrate the principles and lead us to the relevant SORT guidelines (https://www.sort.nhs.uk/Guidelines/Guidelines-A-to-Z.aspx):
- Case 1: Relevant guidelines: Bronchiolitis; Ventilation Initiation; Intubation Checklist; Caring for the Ventilated Child Whilst Awaiting SORT/Retrieval
- Case 2: Relevant guidelines: Sepsis Screening Tool and Quick Reference Guidelines; IO Insertion Guide and IO Observations
- Case 3: Relevant guidelines: Decreased Level of Consciousness (DeCon) – links to RCPCH guideline: https://www.rcpch.ac.uk/sites/default/files/2019-04/RCPCH%20DeCon%20Poster_R9%20A1%20updated%20April%202019.pdf
- Case 4: Relevant guidelines: Neonatal Collapse. Don’t forget SCAMS (sepsis, cardiac, abuse, metabolic, something else?). There’s also a useful podcast on the subject by @medsquire https://intensivecarenetwork.com/paediatric-icu-part-4-the-shocked-neonate/
Also useful are the Drug Calculator (everyone’s favourite) Drug Infusion Guide, Infusion Calculators and Handover of a PICU Patient guidelines.
Always try to use your local area’s guidelines, such as STRS https://www.evelinalondon.nhs.uk/our-services/hospital/south-thames-retrieval-service/clinical-guidelines.aspx depending on where you are!
Another gem is that lack of interest in tech is a late sign in a sick child – much like dropping BP – Beware the tech-positive child (and even more so the tech-negative one)!
Last but definitely not least was a Covid-19 update in children, given by our very own Twitter-famous @apsmunro
A good summary of this info can be found on the Don’t Forget the Bubbles website: https://dontforgetthebubbles.com/evidence-summary-paediatric-covid-19-literature/
As well as info on children and transmission: https://dontforgetthebubbles.com/the-missing-link-children-and-transmission-of-sars-cov-2/ and the PIMS-TS phenomenon: https://dontforgetthebubbles.com/pims-ts/
Overall a successful day, with much learnt by all. I will leave you with some handy tips from @CChaseUk about hosting a virtual event. See you at the next PEMSoC!
PEMSoC 