smaccMINI summary: Paediatric Critical Care Workshop for non-paediatricians

Good day badEM followers.. as you know @craigwylie & myself (@kat__evans) are at #smaccDUB in Ireland. I attended smaccMINI whilst Craig was attending smaccFORCE (prehospital workshop – his summary to follow in the days to come)

Resuscitation Update by @_NMay

• Natalie has done the summarising already in the below post!
• http://stemlynsblog.org/smaccmini-pls/

 Approaches to spotting the sick child Rachel Rowlands

• This was a talk that struck home for me as I have previously lost a patient from oesophageal perforation & mediastinitis due to missed button battery ingestion. Rachel spoke about a case she cared for in a child that developed an aortic-oesophageal fistula – presented with very subtle symptoms.

My thoughts/musings: In LMIC settings we need to fight for these patients – they must get to a hospital that can do emergent scope on a child! Don’t let the surgeon tell you to send the patient the next morning! This can require a very long transport time & difficult logistics if in rural. Be your patients advocate! Sometimes our patients in low resource settings present very late! Always ask about foreign body ingestion or availability of button battery in house in a child with unexplained drooling, sepsis, features of mediastinitis, left pleural effusion or pneumopericardium on CXR. Also LOOK for a button battery/foreign bodies on ALL paediatric X-rays!

• See the below video of another conference where she discussed this case:
• www.tinyurl.com/bebatteryaware
• Watch the below time-lapse video on what a button battery does to Polony! Really helps to visualise it:

• Thanks for the video links Rachel!

PEM Literature Update @emtogether

• See slides here: 
• http://pemplaybook.org/wp-content/uploads/2016/01/PEM-Lit-Update-2016.pdf

 

My personal low-middle income country (LMIC) considerations: The above slide by the speaker jumped out at me as critically important for our LMIC environments.. Thanks for considering our settings! Every intervention needs to be appropriate for the resource environment! Have to think about what interventions are going to have the greatest impact on a large scale.

We definitely need more CPAP use in our setting – can use an autoclavable Mapelson F (+Jackson Rees modification) circuit for this, you don’t need a fancy machine! At the recent ICEM conference in Cape Town we heard from our Indian colleagues how they are very successfully using CPAP via Mapelson F (mask held by parents!) in a very resource limited environment. See below for picture of what this looks like:

 

Sick neonates are simple @tisheewoods

• Trish says its best: “actually they are a nightmare UNTIL you appreciate transitioning from fetal to neonatal state”

 

• Some of the audience summarised key points nicely:

Mistakes & pitfalls in critical care @philhyde_1

• I have crowdsourced key learning points from other speakers/delegates!

• Check out the below great resource mentioned in the talk:
• www.spottingthesickchild.com

Paediatric Ultrasound @broomedocs

• Absolutely brilliant ultrasound talk by Casey Parker!
• The blog post sent out for “workshop pre-reading” was the best I have read on paediatric lung ultrasound! It has been very useful in my department over the last few weeks! Thanks Casey!
• Check post out here: http://broomedocs.com/2016/03/pneumonia-ultrasound-diagnostic-strategy/

 

• *NB* Dont forget the axilla

Personal low-middle income country (LMIC) considerations/musings:

We had an interesting twitter discussion after the presentation regarding how with Ultrasound we pick up a lot more tiny pleural effusions than with CXR.

• In most settings these are simple parapneumonic effusions & will resolve with antibiotics.
• In areas of high TB prevalence, when we find a pleural effusion, we must check the childs growth/weight, check for lymphadenopathy, consider a mantoux (environment specific) & do CXR to look for other features of TB such as cavitation, military picture & hilar lymphadenopathy.

 What paediatric surgeons wish you knew @ffolliet

 

• Only fix umbilical hernias at 4 years.
• Paediatric surgeon only ever seen 2 incarcerated umbilical hernias – both in children with metabolic diseases

• See a prolapse.. push it back!

One thing I didn’t ask the speaker (will ask via twitter & post reply here!) is that I have seen intususseption that looks remarkably like a rectal prolapse (trick: to tell the difference see if you can get your finger “around” the edge).. perhaps this is a problem predominantly in our setting? Do our intususseption patients just present a lot more delayed than in the developed world. Clearly this is a far more dangerous diagnosis than rectal prolapse & shouldn’t be sent home, easy to examine if you know what to look for.

Paediatric Toxicology @turtle1doc

• eCigarettes refills:
• Nicotine toxicity – traditionally toxic dose thought to be 1mg/kg but latest evidence looks more like 10mg/kg.
• No role for charcoal.
• Watch out for cholinergic toxidrome – consider atropine infusion.

 Paediatric Trauma by @_NMay

 

Excellence in critical care @adrianplunkett

• Fantastic project implemented with reporting of excellence in multidisciplinary setting. One would think this would be the polar opposite to Adverse Event reporting but actually has massive overlap.
• Great team morale boosting.
• It was rapidly adopted and supported (including other departments in hospital)

LMIC: I feel in an environment with high morbidity & mortality rates, massive EC overcrowding & high adverse event rate (predominantly unreported) this can be an excellent tool. Morale can be low & doctors can reach the point where they feel they “aren’t winning” & that “nothing is ever good enough” Excellence reporting gives team members commendation for good work being done & with snowball effect motivates staff to go “above & beyond”

Communication: kids & families @rosilvergrove

Communication: adolescents @fakethom

• Whilst in South Africa we are certainly leagues ahead of many other African countries with regards to stigma against LGBT people, there is a lot more we can do to improve communication.
• Emergency Centres are often only access point to healthcare. In EM we have been shown to respond poorly & correct communication is essential. Make sure to use correct pronouns! Absolutely brilliant Vodcast!

• Recommended article on inclusive language:
• http://www.equalitiesinhealth.org/public_html/documents/InclusiveLanguage-NHS_000.pdf

Resource poor settings @turtle1doc

• Great to hear a talk that really puts into context the importance of effective team communication of limitations of care that can be provided in low resource settings.
• Cholera & measles management in tent setups in outbreaks.
• Cannot start CPR in environment where there is no potential for a ventilator, intensive care etc.
• Interesting to hear of the massive under 5 mortality & how that seems to link to the expression of grief in parents, with so many children dying under 5 that becomes the “norm”.
• Cultural misunderstandings: Families link the oxygen or intraosseous lines as markers of death, & at times refused these interventions due to perceptions that they lead to death.
• Very easy to see how this can happen. Whilst we don’t work in such a low resource environment, we do certainly see a broad range of patients in our setting, including parents that demand intravenous fluids (worldwide issue) & we do see those parents that refuse IV fluids in actively dying child due to what I have always presumed denial of severity “my child is not that sick doctor”

Complex Kids @emtogether

Surgical surprises @ffoliet

• Check out this speakers website www.prezentationskills.blogspot.com
• See below tweet (plus he suggested putting a sanitary pad inside the cling wrap on either side of the defect to support bowel)

 

Neonatal procedure tips @tisheewoods

• Don’t let go of the umbilical line once in – it will pop back out at you!
• Don’t dab.. wastes time.
• If you go into where the blood is pouring out of you are probably safe
• 5cm depth is a rough general estimate.
• We discussed skin prep in the neonate for securing endotracheal tubes. Check out this great article tweeted out to me in reply to my question after the talk: http://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Neonatal___Infant_Skin_Care/

Intubation tips @emtogether

• See full slides here:
• http://pemplaybook.org/wp-content/uploads/2016/01/Airway-Master-Moves_Horeczko.pdf
• Some considerations to think about: consider a jaw thrust DURING laryngoscopy & don’t forget to consider a towel under the shoulders for alignment

Patient experience @_NMay @rosilvergrove

• Fantastic presentation by an 11 year old girl discharged from ICU 4 months ago after ventilation for tracheitis.
• Take home: Dont use long words!
• Explain what is going on at all times.
• Introduce yourself, she distinctly remembered 2 emergency room staffs first names & them being really nice and she felt safe – Kate Granger from hellomynameis.. would be proud!
• She found being in ICU scary with all the people having to wear gowns & masks.
• She was discharged 3 days earlier than expected & very “suddenly”.. gave patient & parents great anxiety over the weekend.
• Patient also wished there were pictures on the ICU wall opposite her bed that she could look at.

My personal LMIC musings/considerations: In particular in an environment where the doctor does not speak the childs first language there is a tendency to communication “over the childs head” with the parent who does speak the language. Need to remember that the child is your patient first and parent second. Engage with a college that can speak the childs language to support them.