Lots of good stuff again from the virtual #RCEMasc21 –  here are a few of the topics that got me thinking

Sepsis – Timing of antibiotics

• This retrospective single site cohort paper – looked at factors affecting mortality in Sepsis patients
• It found:
  • “Septic Shock patients” Giving antibiotics in <55min had a massive mortality benefit and a NNT=4
  • But NO mortality befit in the “All septic patients group” for IV antibiotics given <1hr vs >1hr
• This fits to the findings of a recent meta-analysis by Rotherick et. al. 2020 
• Bottomline:
  • Treat Septic Shock Fast <1hr – it saves lives!
  • Timing of antibiotics generally in sepsis? – Keep aiming for 1hr, we prob needs to have a trust discussion regarding: resource, stewardship & outcomes.

 

Pediatric MAJAX Triage (Pre-Print article)

• This study examined 4 different paediatric MAJAX triage tools
  • 2 current tools , a proposed tool from Sheffield and the standard Adult tool
• The Sheffield(SPTT) and Adult (MPTT-24) tools both out performed our currently tools [SPTT (right) MPTT-24 (left)]
• However, the Adult (MPTT-24) is simpler and more familier
• Bottomline: we will. need to await publication but one to think about for MAJAX committees

 

Children with Fever and Non-Blanching Rash – PiC study

• If they look sick its easy(treat meningitis) but what about those well looking ones?
• The study examined the sensitivity and specificity and cost for picking up serious illness, of Trust guidelines from around the UK + NICE
• All 100% sensitive for Meningitis and serious infections
• Specificity varied from 0% with NICE to 36% for the best performing (BART’s guideline)
• However, for Doctors going off guide, sensitivity dropped to 89%

Risk of missing Orbital Cellulitis in children

• So you think the kid may have peri-orbital cellulitis – should you go oral antibiotics and go home or should you give IV’s and keep in?
• This study recruited 216 children with ? periodical cellulitis.
• 5/216 had potentially missed orbital cellulitis
  • 5/5 had fever (31% of periodical cellulitis)
  • 4/5 had vomiting or headache (3% of periorbital cellulitis)
  • 1/5 was an infant who was difficult to examine and not chatty about any headaches
  • All got IV medication
• 3% of those started on oral medication – returned requiring IV’s
• Recommdation in paper : use the ASSET score (4+) to differentiate between oral and IV groups (below)
  • Reduced IV antibiotic use
  • Picked up all the orbital cellulitis children and those who represented
• Bottomline:
  • Guess orbital cellulitis if the patient has fever or systemic features.
  • Discussion with Paeds team about adoption of ASSET genrally

Other Interesting Bits

• What animal are you?
  • find your personality on icould buzz quiz (100% susses for my family)
  • should we all weara badge – to warn others??
  • Bottomline: Tawny Owls rule!
• Huddles
  • Should seniors ask – “what are your learning objective for the day?”
  • Should we so a mental rehearsal/sim of a case? – found to identify service and knowledge gaps
• Ultrasound Pulse check in CPR
  • feeling pulses can be difficult and slow during CPR – should we think about ultrasound?
  • POCUS pulse check (5.39s)  vs Manual pulse check (6.40s)
    • p value <0.001
• Concussion
  • not as simple as it seems
  • 30-50% have persistent symptoms for >6months
  • Should we be using SCATs tool – ?
  • What follow up is there – ?
  • Do we need better patient advice – Yes
• Injuries
  • Remember!: X-rays are just a test they can be wring (as usual Hx and Ex improtant
  • If X-ray -ve think what are you SCAReD OF?
    • Septic arthritis
    • Compartment synd
    • Abuse
    • Referred pain/Report wrong
    • Dislocation/subluxation
    • Operative soft tissue injury
    • Fracture (occult)