Region-Specific Microstructure in the Neonatal Ventricles of a Porcine Model.

The neonate transitions from placenta-derived oxygen, to supply from the pulmonary system, moments after birth. This requires a series of structural developments to divert more blood through the right heart and onto the lungs, with the tissue quickly remodelling to the changing ventricular workload. In some cases, however, the heart structure does not fully develop causing poor circulation and inefficient oxygenation, which is associated with an increase in mortality and morbidity. This study focuses on developing an enhanced knowledge of the 1-day old heart, quantifying the region-specific microstructural parameters of the tissue. This will enable more accurate mathematical and computational simulations of the young heart. Hearts were dissected from 12, 1-day-old deceased Yorkshire piglets (mass: 2.1-2.4 kg, length: 0.38-0.51 m), acquired from a breeding farm. Evans blue dye was used to label the heart equator and to demarcate the left and right ventricle free walls. Two hearts were used for three-dimensional diffusion-tensor magnetic resonance imaging, to quantify the fractional anisotropy (FA). The remaining hearts were used for two-photon excited fluorescence and second-harmonic generation microscopy, to quantify the cardiomyocyte and collagen fibril structures within the anterior and posterior aspects of the right and left ventricles. FA varied significantly across both ventricles, with the greatest in the equatorial region, followed by the base and apex. The FA in each right ventricular region was statistically greater than that in the left. Cardiomyocyte and collagen fibre rotation was greatest in the anterior wall of both ventricles, with less dispersion when compared to the posterior walls. In defining these key parameters, this study provides a valuable insight into the 1-day-old heart that will provide a valuable platform for further investigation the normal and abnormal heart using mathematical and computational models.

Selecting children for head CT following head injury.

OBJECTIVE: Indicators for head CT scan defined by the 2007 National Institute for Health and Care Excellence (NICE) guidelines were analysed to identify CT uptake, influential variables and yield. DESIGN: Cross-sectional study. SETTING: Hospital inpatient units: England, Wales, Northern Ireland and the Channel Islands. PATIENTS: Children (<15 years) admitted to hospital for more than 4 h following a head injury (September 2009 to February 2010). INTERVENTIONS: CT scan. MAIN OUTCOME MEASURES: Number of children who had CT, extent to which NICE guidelines were followed and diagnostic yield. RESULTS: Data on 5700 children were returned by 90% of eligible hospitals, 84% of whom were admitted to a general hospital. CT scans were performed on 30.4% of children (1734), with a higher diagnostic yield in infants (56.5% (144/255)) than children aged 1 to 14 years (26.5% (391/1476)). Overall, only 40.4% (984 of 2437 children) fulfilling at least one of the four NICE criteria for CT actually underwent one. These children were much less likely to receive CT if admitted to a general hospital than to a specialist centre (OR 0.52 (95% CI 0.45 to 0.59)); there was considerable variation between healthcare regions. When indicated, children >3 years were much more likely to have CT than those <3 years (OR 2.35 (95% CI 2.08 to 2.65)). CONCLUSION: Compliance with guidelines and diagnostic yield was variable across age groups, the type of hospital and region where children were admitted. With this pattern of clinical practice the risks of both missing intracranial injury and overuse of CT are considerable.

Epidemiology of children with head injury: a national overview.

BACKGROUND: The National Confidential Enquiry describes the epidemiology of children admitted to hospital with head injury. METHOD: Children (<15 years old) who died or were admitted for >4 h with head injury were identified from 216 UK hospitals (1 September 2009 to 28 February 2010). Data were collected using standard proformas and entered on to a database. A descriptive analysis of the causal mechanisms, child demographics, neurological impairment, CT findings, and outcome at 72 h are provided. RESULTS: Details of 5700 children, median age 4 years (range 0-14.9 years), were analysed; 1093 (19.2%) were <1 year old, 3500 (61.4%) were boys. There was a significant association of head injury with social deprivation 39.7/100 000 (95% CI 37.0 to 42.6) in the least deprived first quintile vs. 55.1 (95% CI 52.1 to 58.2) in the most deprived fifth quintile (p<0.01). Twenty-four children died (0.4%). Most children were admitted for one night or less; 4522 (79%) had a Glasgow Coma Scale score of 15 or were Alert (on AVPU (Alert, Voice, Pain, Unresponsive)). The most common causes of head injury were falls (3537 (62.1%); children <5 years), sports-related incidents (783 (13.7%); median age 12.4 years), or motor vehicle accidents (MVAs) (401 (7.1%); primary-school-aged children). CT scans were performed in 1734 (30.4%) children; 536 (30.9%) were abnormal (skull fracture and/or intracranial injury or abnormality): 269 (7.6%) were falls, 82 (10.5%) sports related and 100 (25%). A total of 357 (6.2%) children were referred to social care because of child protection concerns (median age 9 months (range 0-14.9 years)). CONCLUSIONS: The data described highlight priorities for targeted age-specific head injury prevention and have the potential to provide a baseline to evaluate the effects of regional trauma networks (2012) and National Institute of Health and Care Excellence (NICE) head injury guidelines (2014), which were revised after the study was completed.

Performance characteristics of five triage tools for major incidents involving traumatic injuries to children.

UNLABELLED: Context Triage tools are an essential component of the emergency response to a major incident. Although fortunately rare, mass casualty incidents involving children are possible which mandate reliable triage tools to determine the priority of treatment. OBJECTIVE: To determine the performance characteristics of five major incident triage tools amongst paediatric casualties who have sustained traumatic injuries. DESIGN, SETTING, PARTICIPANTS: Retrospective observational cohort study using data from 31,292 patients aged less than 16 years who sustained a traumatic injury. Data were obtained from the UK Trauma Audit and Research Network (TARN) database. Interventions Statistical evaluation of five triage tools (JumpSTART, START, CareFlight, Paediatric Triage Tape/Sieve and Triage Sort) to predict death or severe traumatic injury (injury severity score >15). Main outcome measures Performance characteristics of triage tools (sensitivity, specificity and level of agreement between triage tools) to identify patients at high risk of death or severe injury. RESULTS: Of the 31,292 cases, 1029 died (3.3%), 6842 (21.9%) had major trauma (defined by an injury severity score >15) and 14,711 (47%) were aged 8 years or younger. There was variation in the performance accuracy of the tools to predict major trauma or death (sensitivities ranging between 36.4 and 96.2%; specificities 66.0-89.8%). Performance characteristics varied with the age of the child. CareFlight had the best overall performance at predicting death, with the following sensitivity and specificity (95% CI) respectively: 95.3% (93.8-96.8) and 80.4% (80.0-80.9). JumpSTART was superior for the triaging of children under 8 years; sensitivity and specificity (95% CI) respectively: 86.3% (83.1-89.5) and 84.8% (84.2-85.5). The triage tools were generally better at identifying patients who would die than those with non-fatal severe injury. CONCLUSION: This statistical evaluation has demonstrated variability in the accuracy of triage tools at predicting outcomes for children who sustain traumatic injuries. No single tool performed consistently well across all evaluated scenarios.

Head injury from falls in children younger than 6†years of age.

UNLABELLED: The risk of serious head injury (HI) from a fall in a young child is ill defined. The relationship between the object fallen from and prevalence of intracranial injury (ICI) or skull fracture is described. METHOD: Cross-sectional study of HIs from falls in children (<6 years) admitted to UK hospitals, analysed according to the object fallen from and associated Glasgow Coma Score (GCS) or alert, voice, pain, unresponsive (AVPU) and CT scan results. RESULTS: Of 1775 cases ascertained (median age 18 months, 54.7% boys), 87% (1552) had a GCS=15/AVPU=alert. 19.3% (342) had a CT scan: 32% (110/342) were abnormal; equivalent to 5.9% of the overall population, 16.9% (58) had isolated skull fractures and 13.7% (47) had ICI (49% (23/47) had an associated skull fracture). The prevalence of ICI increased with neurological compromise; however, 12% of children with a GCS=15/AVPU=alert had ICI. When compared to falls from standing, falls from a person's arms (233 children (mean age 1 year)) had a significant relative OR for a skull fracture/ICI of 6.94 (95% CI 3.54 to 13.6), falls from a building (eg, window or attic) (mean age 3 years) OR 6.84 (95% CI 2.65 to 17.6) and from an infant or child product (mean age 21 months) OR 2.75 (95% CI 1.36 to 5.65). CONCLUSIONS: Most HIs from a fall in these children admitted to hospital were minor. Infants, dropped from a carer's arms, those who fell from infant products, a window, wall or from an attic had the greatest chance of ICI or skull fracture. These data inform prevention and the assessment of the likelihood of serious injury when the object fallen from is known.

Paediatric community-acquired septic shock: results from the REPEM network study.

UNLABELLED: INTRODUCTION AND PURPOSE OF THE STUDY: With this study we aimed to describe a "true world" picture of severe paediatric 'community-acquired' septic shock and establish the feasibility of a future prospective trial on early goal-directed therapy in children. During a 6-month to 1-year retrospective screening period in 16 emergency departments (ED) in 12 different countries, all children with severe sepsis and signs of decreased perfusion were included. RESULTS: A 270,461 paediatric ED consultations were screened, and 176 cases were identified. Significant comorbidity was present in 35.8 % of these cases. Intensive care admission was deemed necessary in 65.7 %, mechanical ventilation in 25.9 % and vasoactive medications in 42.9 %. The median amount of fluid given in the first 6 h was 30 ml/kg. The overall mortality in this sample was 4.5 %. Only 1.2 % of the survivors showed a substantial decrease in Paediatric Overall Performance Category (POPC). 'Severe' outcome (death or a decrease ≥2 in POPC) was significantly related (p < 0.01) to: any desaturation below 90 %, the amount of fluid given in the first 6 h, the need for and length of mechanical ventilation or vasoactive support, the use of dobutamine and a higher lactate or lower base excess but not to any variables of predisposition, infection or host response (as in the PIRO (Predisposition, Infection, Response, Organ dysfunction) concept). CONCLUSION: The outcome in our sample was very good. Many children received treatment early in their disease course, so avoiding subsequent intensive care. While certain variables predispose children to become septic and shocked, in our sample, only measures of organ dysfunction and concomitant treatment proved to be significantly related with outcome. We argue why future studies should rather be large multinational prospective observational trials and not necessarily randomised controlled trials.

Prehospital paediatric emergency care: paediatric triage.

The practice of triage was conceived during the Napoleonic wars, with the aim of salvaging those soldiers whose injuries were readily treatable, returning them to the battlefield at the earliest opportunity. Literally, the word triage means "to sieve" or "to sort" (French trier), and those earlier battlefield principles have been refined and expanded to now encompass trauma and medical emergencies, with triage practiced in prehospital and hospital settings. To address the anatomical, physiological and developmental differences encountered when dealing with children, specific paediatric triage systems have also been developed, and this article discusses their merits.

The relationship between body temperature, heart rate and respiratory rate in children.

AIM: To describe and quantify the effect that increasing body temperature has on heart rate and respiratory rate in children attending a paediatric emergency department (ED). METHODS: Data on pulse, temperature, respiratory rate and age were collected from attendances to two children's ED in the UK between 2003 and 2006. Triage observations as documented at the time were collated and analysed. RESULTS: Data on a total of 63 857 attendances were examined, 31 851 with complete data. Data on children not sent home from the ED were removed, to exclude any patient with haemodynamic shock. The remaining dataset of 21 033 patients with data for heart rate and 14 487 with data for respiratory rate were studied. The state of agitation of the patient was not considered in this study. CONCLUSION: Body temperature is an independent determinant of heart rate, causing an increase of approximately 10 beats per minute per degree centigrade. Body temperature is also an independent determinant of respiratory rate. This quantification may help in the assessment of the hot and unwell child, to determine whether any tachycardia or tachypnoea is caused solely by fever, or whether there may be an element of concurrent shock.

Debriefing after failed paediatric resuscitation: a survey of current UK practice.

OBJECTIVES: Debriefing is a form of psychological "first aid" with origins in the military. It moved into the spotlight in 1983, when Mitchell described the technique of critical incident stress debriefing. To date little work has been carried out relating to the effectiveness of debriefing hospital staff after critical incidents. The aim of this study was to survey current UK practice in order to develop some "best practice" guidelines. METHODS: This study was a descriptive evaluation based on a structured questionnaire survey of 180 lead paediatric and emergency medicine consultants and nurses, selected from 50 UK trusts. Questions collected data about trust policy and events and also about individuals' personal experience of debrief. Free text comments were analyzed using the framework method described for qualitative data. RESULTS: Overall, the response rate was 80%. 62% said a debrief would occur most of the time. 85% reported that the main aim was to resolve both medical and psychological and emotional issues. Nearly all involve both doctors and nurses (88%); in over half (62%) other healthcare workers would be invited, eg, paramedics, students. Sessions are usually led by someone who was involved in the resuscitation attempt (76%). This was a doctor in 80%, but only 18% of responders said that a specifically trained person had led the session. Individuals' psychological issues would be discussed further on a one-to-one basis and the person directed to appropriate agencies. Any strategic working problems highlighted would be discussed with a senior member of staff and resolved via clinical governance pathways. CONCLUSIONS: Little is currently known about the benefits of debriefing hospital staff after critical incidents such as failed resuscitation. Debriefing is, however, widely practised and the results of this study have been used to formulate some best practice guidelines while awaiting evidence from further studies.

Fluid therapy for acute bacterial meningitis.

BACKGROUND: Acute bacterial meningitis remains a disease with high mortality and morbidity rates. However, with prompt and adequate antimicrobial and supportive treatment, the chances for survival have improved, especially in infants and children. Careful management of fluid and electrolyte balance is an important supportive therapy. Both over- and under-hydration are associated with adverse outcomes. OBJECTIVES: To evaluate differing volumes of fluid given in the initial management of bacterial meningitis. SEARCH STRATEGY: We searched the Cochrane Acute Respiratory Infection Group's trials register, the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 1), MEDLINE (1966 to March 2007), EMBASE (1980 to March 2007), and CINAHL (1982 to February 2007). SELECTION CRITERIA: Randomised controlled trials of differing volumes of fluid given in the initial management of bacterial meningitis were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Six trials were identified in the initial search. On careful inspection three of these met the inclusion criteria. Data were extracted and trials were assessed for quality by all four of the original review authors (one author, R.O.W. has died since the original review, see acknowledgements). Data were combined for meta-analysis using relative risks for dichotomous data or weighted mean difference for continuous data. A fixed-effect statistical model was used. MAIN RESULTS: The largest of the three trials was conducted in settings with high mortality rates. The meta-analysis found no significant difference between the maintenance-fluid and restricted-fluid groups in number of deaths (RR 0.82, 95% CI 0.53 to 1.27); acute severe neurological sequelae (RR 0.67, 95% CI 0.41 to 1.08); or in mild to moderate sequelae (RR 1.24, 95% CI 0.58 to 2.65). However, when neurological sequelae were defined further, there was a statistically significant difference in favour of the maintenance-fluid group in regard to spasticity (RR 0.50, 95% CI 0.27 to 0.93), seizures at both 72 hours (RR 0.59, 95% CI 0.42 to 0.83) and 14 days (RR 0.19, 95% CI 0.04 to 0.88), and chronic severe neurological sequelae at three-months follow up (RR 0.42, 95% CI 0.20 to 0.89). AUTHORS' CONCLUSIONS: Some evidence supports maintaining intravenous fluids rather than restricted them in the first 48 hours, in settings with high mortality rates and where patients present late. However, where children present early and mortality rates are lower there is insufficient evidence to guide practice.

Salicylate for the treatment of Kawasaki disease in children.

BACKGROUND: Kawasaki disease is the most common cause of acquired heart disease in children in developed countries. The coronary arteries supplying the heart can be damaged in Kawasaki disease. The principal advantage of timely diagnosis is the potential to prevent this complication with early treatment. Salicylate (acetyl salicylate acid (ASA), aspirin) and intravenous immunoglobulin (IVIG) are widely used for this purpose. Salicylate is largely otherwise avoided in children because of concerns about serious side effects, particularly the risk of Reyes syndrome. OBJECTIVES: The objective of this review was to evaluate the effectiveness of salicylate in treating and preventing cardiac consequences of Kawasaki disease in children. SEARCH STRATEGY: The Cochrane Peripheral Vascular Disease Group searched their trials register (last searched July 2006) and the Cochrane Central Register of Controlled Trials (CENTRAL) (last searched Issue 3, 2006). We searched MEDLINE (January 1966 to July 2006), EMBASE (January 1980 to July 2006), and CINAHL (1982 to July 2006), and reference list of articles. In addition we contacted experts in the field. SELECTION CRITERIA: Randomised controlled trials (RCTs) of salicylate to treat Kawasaki disease in children were eligible for inclusion. DATA COLLECTION AND ANALYSIS: Two authors independently assessed trial quality and extracted data. Study authors were contacted for additional information. MAIN RESULTS: We found one trial involving 102 children which was described as randomised, but it was not possible to confirm the method of treatment allocation. A second comparative study, possibly with a randomised treatment allocation, was also identified. The one randomised trial reported no association between the addition of ASA to IVIG treatment on the rate of coronary artery abnormalities at follow up, but with wide confidence limits. The second, possibly randomised trial did demonstrate a reduction in duration of fever with high dose ASA compared to low dose ASA, but was insufficiently powered to establish the effect on coronary artery abnormalities at follow up. AUTHORS' CONCLUSIONS: Until good quality RCTs are carried out, there is insufficient evidence to indicate whether children with Kawasaki disease should continue to receive salicylate as part of their treatment regimen.