Monthly Archives: February 2012

NICE on anaphylaxis

For Emergency Departments, For General Practitioners, ,

With thanks to my colleague, Dr Su Li, for summarising this 2011 NICE guideline for Paediatric Pearls.

Anaphylaxis: assessment to confirm an anaphylactic episode and the decision to refer after emergency treatment for a suspected anaphylactic episode

December 2011

www.nice.org.uk/cg134

Anaphylaxis is a severe, life-threatening, generalised hypersensitivity reaction involving

  • the airway (pharyngeal or laryngeal oedema) and/or
  • breathing (bronchospasm, tachypnoea) and/or
  • circulation (hypotension, tachycardia).

 

There can often be skin and mucosal changes. Patients presenting with these signs and symptoms should be diagnosed as having ‘suspected anaphylaxis’.

Anaphylaxis may be an allergic response that is

  • immunologically IgE mediated (foods, venoms, drugs, latex) or
  • non-immunologically mediated or
  • idiopathic (significant clinical effects with no obvious cause).

 

This guideline does not make any drug recommendations. These can be found at http://www.resus.org.uk/pages/reaction.pdf.

Patient Centred Care

  • Treatment and care should take into account patient’s needs and preferences
  • Patients should have the opportunity to make informed decisions about their care and treatment, in partnership with health care professionals
  • Good communication between healthcare professionals and patients is essential
  • Families and carers should be given the information and support they need
  • Care of young people in transition between paediatric and adult services should be planned and managed according to the best practice guidance described in ‘Transition: getting it right for young people’

 

Recommendations

  • Document acute clinical features of the suspected anaphylaxis
  • Record the time of onset
  • Record the circumstances immediately before the onset of symptoms to help identify possible triggers

 

  • Consider taking blood samples for mast cell tryptase if reaction is thought to be immunologically mediated or idiopathic
    • First sample as soon after emergency treatment given
    • Second sample 1-2 hours (no more than 4 hours) from onset of symptoms
    • A further sample may be required at follow up with the allergy specialist to measure baseline mast cell tryptase

 

  • Children who have had emergency treatment should be admitted to hospital under the care of the paediatric team.  The resus council suggests observing the child for a pragmatic (no evidence yet) 6 hours because of the risk of a biphasic reaction.
  • Offer the child/parents a referral to an allergy specialist (see www.bsaci.org for registered allergy clinics)
  • Offer the child/parents an adrenaline injector in the interim period whilst waiting for a specialist appointment

 

  • Before discharge, offer the child/parents
    • Information about anaphylaxis (signs, symptoms, risk of recurrence of symptoms (biphasic reaction)).  Parent information leaflet here.
    • Information about what to do if a reaction occurs (use adrenaline injector, call emergency services)
    • Demonstration on how to use an adrenaline injector see http://www.youtube.com/watch?v=pgvnt8YA7r8 for a clear American description of how to use it.
    • Advice about how to avoid potential triggers
    • Information about the need for referral and the referral process to an allergy specialist
    • Information about patient support groups

 

Research Recommendations

  • Mast cell tryptase is not always elevated in children, particularly if food is thought to be the allergen or if respiratory compromise is the main clinical feature. It is recommended that further studies be carried out to identify other potential chemical inflammatory mediators.
  • There is limited evidence on biphasic reactions. Follow up studies are recommended.
  • There are no studies on length of observation period following emergency treatment for suspected anaphylaxis
  • There is limited data on the annual incidence or anaphylactic reactions and their associated outcomes.
  • The Guideline Development Group feel that referral to specialist services and/or the provision of adrenaline injectors are likely to benefit patients who have experienced a suspected anaphylaxis as a result of decreased anxiety and ongoing support. This benefit is yet to be quantified.

Pulled elbow

For Emergency Departments, For General Practitioners,

Dr Furqan Ahmed is an Emergency Medicine middle grade doctor seconded to paediatrics for a few months as part of his training.  I hope he is learning from us, we are certainly picking up things from him.  He has put together the following guide to “pulled elbow” or “radial head subluxation” for Paediatric Pearls.

Pulled elbow, Nursemaid’s elbow, is a dislocation of the elbow joint caused by a sudden pull on the extended, pronated arm. The technical term for the injury is radial head subluxation.

Pathophysiology:

The etiology is slippage of the head of the radius under the annular ligament. The distal attachment of the annular ligament covering the radial head is weaker in children than in adults, allowing it to be more easily torn.

As children age, the annular ligament strengthens, making the condition less common. The oval shape of the proximal radius in cross-section contributes to this condition by offering a more acute angle posteriorly and laterally, with less resistance to slippage of the ligament when axial traction is applied to the extended and pronated forearm.

Causes, incidence, and risk factors

Radial head subluxation is a common pediatric presentation generally occurring between the ages of 1 and 4 years, although it can happen anytime between 6 months of age and 7 years. After age 3, children’s joints and ligaments gradually grow stronger, making radial head subluxation less likely to occur.

The injury occurs when a child is pulled up too hard by the hand or wrist. It is often seen after someone lifts a child up by one arm (eg. when trying to lift the child over a curb or high step).

Other ways this injury may happen include:

  • Breaking a fall with the arm
  • Rolling over in an unusual way
  • Swinging a young child from the arms while playing

 

Signs and symptoms

When the injury occurs, the child usually begins crying right away and refuses to use the arm because of elbow pain.

  • The child may hold the arm slightly bent (flexed at 15-20 degrees) at the elbow and pressed up against the abdominal area (pronated).
  • The child will move the shoulder, but not the elbow. Some children stop crying as the first pain goes away, but continue to refuse to move the elbow.
  • Tenderness at the head of the radius may be present.
  • Erythema, warmth, oedema, or signs of trauma are absent.
  • Distal circulation, sensation, and motor activity are normal

Treatment

Inform child and caregiver that the reduction may be uncomfortable, but the discomfort will end quickly after reduction. Parents should not attempt these manoeuvres at home unless advised by a physician.

To resolve the problem, the affected arm must be held with one hand/finger on the radial head and the other grasping the hand making sure the elbow is in 90° of flexion. While applying compression between these two hands, the forearm of the patient is gently supinated and the arm flexed. The manipulator will usually feel a “click” if the manoeuvre is done properly, the child will feel momentary pain, and usually within 5 minutes, the forearm will be functioning well and painlessly.  NB: although a ‘click’ signifies reduction, absence of a ‘click’ is noted in some successful reductions.

Differential diagnoses:

  • Fracture, Elbow
  • Fracture, Wrist
  • Hand Injury, Soft Tissue

 

Indication for xray:

Child not using arm 30 minutes after a reduction.  External signs of trauma such as swelling, abrasions, or ecchymoses.

Consultations

If radiographic findings demonstrate no fracture, repeat attempts at reduction are unsuccessful, and the child does not regain normal function after 30-40 minutes, the safest management is to support the arm in a sling (or splint and sling) and have the child reevaluated in 1-2 days time.

Prognosis

The prognosis is excellent. Parents can be reassured that no permanent injury results from this condition.

For those who have had one occurrence, the chance of recurrence is approximately 20-25%.  Those 24 months and younger may have the greatest risk of recurrence.

 

References

  1. ^ Krul M, van der Wouden JC, van Suijlekom-Smit LW, Koes BW (2012). “Manipulative interventions for reducing pulled elbow in young children”. Cochrane Database Syst Rev (1): CD007759. doi:10.1002/14651858.CD007759.pub3. PMID 22258973. 
  2. ^ Toupin P, Osmond MH, Correll R, Plint A (September 2007). “Radial head subluxation: how long do children wait in the emergency department before reduction?”. CJEM 9 (5): 333–7. PMID 17935648. http://www.cjem-online.ca/v9/n5/p333. 
  3. ^ Kaplan, RE; Lillis, KA (2002 Jul). “Recurrent nursemaid’s elbow (annular ligament displacement) treatment via telephone.”. Pediatrics 110 (1 Pt 1): 171–4. PMID 12093966. 
  4. ^ Macias CG, Bothner J, Wiebe R (July 1998). “A comparison of supination/flexion to hyperpronation in the reduction of radial head subluxations”. Pediatrics 102 (1): e10. PMID 9651462. http://pediatrics.aappublications.org/cgi/pmidlookup?view=long&pmid=9651462.

Down’s syndrome pathways

For General Practitioners

Down’s syndrome occurs in 1:1000 live births and is the commonest identifiable cause of learning difficulties.  There is a significant variability in appearance, personality and levels of general health and independence.  Some medical problems are over-represented in people with Down’s syndrome and, for this reason, this group of children are followed up regularly by a team usually based in the local child development centre.  In Waltham Forest the multidisciplinary Wood Street children’s specialist service team oversee the growth and development of the children with Down’s syndrome, ensuring their health needs are met and their potential for learning maximised.  Click here for their generic Specialist Children’s Services referral form.  See February 2012’s PDF for links to more resources.  I have asked the Wood Street team to add some comments and pathway information below…