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Cite this article as:
Murphy, C. Tongue Lacerations, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.20082

Katie is a 4 year old who presents to your department after a fall off her bike. She landed chin first and has sustained a tongue laceration – she appears to have bitten it. Both her and her mum are very distressed on arrival.

The most common site of injury is the anterior dorsal part of the tongue, which is the surface we see when they tongue is protruded. The next most common is the middle dorsal, and then the ventral aspect. More posterior sites (i.e. the base) are less commonly injured.

When you find one laceration it’s important to look for a second, especially on the other side of the tongue. If there are front and back lacerations, you need to carefully examine them to see if they are connected to make a tract (a through-and-through laceration). These always need to be repaired as they can have poor healing and fistula formation.

The tongue has a large vascular bed and great capacity for regeneration thus making it an ideal candidate for conservative management.

 

Management

A tongue laceration is usually due to trauma. This can range from a simple fall where the tongue is accidentally bitten, to a more serious mechanism. They can also occur in the context of a seizure where the child bites their tongue – don’t forget a full primary and secondary survey. Look for any evidence of head injury. Always remember to assess the neck (particularly if the point of impact has been the chin, they may have hyperextended the neck).

The next step is to assess bleeding: major haemorrhage from the tongue, particularly if one of the volar blood vessels are injured, can threaten the airway. Swelling of the tongue if extensive can also threaten the airway.

You need to assess other intraoral structures for signs of injury eg pharynx, soft palate, teeth.

 If there is evidence of dental injuries (broken teeth, missing teeth) always think about  foreign bodies, e.g. teeth, within the tongue wound, or potential for aspirated foreign bodies/teeth.

 

Analgesia

As with all injuries to children, analgesia should be considered early and often. You are not going to be able to fully assess the tongue and mouth of a distressed/screaming child.

PO/PR paracetamol 15mg/kg and ibuprofen 10mg/kg are a mainstay of treatment.

 Intranasal fentanyl or diamorphine is very useful in this scenario. It has a fast onset of action (7 minutes approximately). It is administered intranasally so they child doesn’t have to put anything in their sore mouth. It is a strong opioid so they will get considerable relief, and it will buy time for the other oral analgesics to start working.

Topical anaesthetics have a role. For example lidocaine soaked gauze can be applied directly to tongue without a need for injecting it. The parent can hold it in place if this makes the child more comfortable. It does have a bitter taste so potentially may not be well tolerated in a younger child.

Regional local anaesthetic blocks are possible in theory but will be difficult in toddlers/younger children, particularly in their distressed phase when they first arrive.

Once reasonable analgesia has been achieved, the wound needs to be thoroughly irrigated in order to clean the wound but also to remove debris to allow for a  full evaluation. During irrigation you should be looking for evidence of foreign bodies or through-and-through lacerations.

 

To close or not to close

 There is evidence that most tongue wounds do very well without intervention / primary closure, even if they are gaping.

 Some studies advocate closure in certain types of wounds :

  • Those with bleeding not controllable with simple means
  • Those that are >2cm in size,
  • Those with >2cm with gaping edges when tongue is at rest.

Wounds that involve the margin or tip still often heal and remodel without closure.

The most recent study published found that larger wounds, with gaping edges, involving the tongue border were more likely to be sutured. However these had a higher rate of complications including wound infections. They also had a longer recovery time (see table). The cosmesis achieved at the end of healing was no better in the sutured group compared to those in the secondary healing group.

 

If closure is needed

If formal closure is needed, the child will usually need to go to theatre. Oral maxillofacial surgeons will repair these in most hospitals. This is because general anaesthetic is usually needed,  and also because an environment where anaesthetics are available to protect the airway due to the risk from bleeding is a must.

A bite block  (eg a rolled up piece of gauze, or a repurposed OPA positioned between the teeth) can keep the mouth open and teeth unclenched.

The tongue will need to be held out of the mouth; this can be achieved by using a large suture through the centre that can be used to pull the tongue out. This will cause further trauma however. The tongue can also be held out using a towel clamp. It then needs to be kept dry and saliva free to achieve a dry field for suturing.

Lidocaine is usually injected for post procedure comfort. The wound will be sutured with an absorbable suture, this negates the potentially difficult and distressing removal of sutures. There is no robust evidence that prophylactic antibiotics are needed, as long as the wound is sufficiently irrigated there is not a big infection risk.

There has been one case report of a tongue laceration that did very well when closed with tissue adhesive, however no robust data supports this.

 

Obviously if the child has other illnesses eg bleeding disorder, you need to liaise with their primary team when making a management plan. There may be a lower threshold for closure to control haemorrhage in these cases and the child will likely need factor replacements.

 

On assessment Katie has a 1cm wound on her dorsal anterior tongue. It gapes when tongue protrudes but not at rest. She has no broken teeth or other intra-oral damage. She is otherwise well, no evidence of head injury or neck injury. She receives analgesia at triage and is not distressed on examination. You decide to manage conservatively after a discussion with her mother. She is discharged with advice about oral hygiene and soft diet for the next few days and advised to return if there are any issues.

 

Selected references

Presenting characteristics and treatment outcomes for tongue lacerations in children.  C. W. Lamell, G. Fraone, P. S. Casamassimo, S. Wilson. Pediatr Dent. 1999 Jan-Feb; 21(1): 34–38.  https://www.ncbi.nlm.nih.gov/pubmed/10029965 

Ud-din Z, Gull S; Should minor mucosal tongue lacerations be sutured in children? Emergency Medicine Journal 2007;24:123-124. https://emj.bmj.com/content/24/2/123.2

Das UM, Gadicherla P. Lacerated tongue injury in children. Int J Clin Pediatr Dent. 2008;1(1):39–41. doi:10.5005/jp-journals-10005-1007 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4086539/

Seiler Michellea, Massaro Sandra Letizia, Staubli Georg, Schiestl Clemens; Tongue lacerations in children: to suture or not? Publication Date: 28.10.2018 Swiss Med Wkly. 2018;148:w14683https://doi.org/10.4414/smw.2018.14683

Pediatric Tongue Laceration Repair Using 2-Octyl Cyanoacrylate (Dermabond®) Kazzi, Massoud G. et al. J Emerg Med 45(6):846–848 https://www.jem-journal.com/article/S0736-4679(13)00462-9/fulltext

The post Tongue Lacerations appeared first on Don't Forget the Bubbles.

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Cite this article as:
DFTB, T. ConSEPT – the reveal: Stuart Dalziel at DFTB18, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.20055

Given that DFTB18 was held in Melbourne it was important to highlight the work of PREDICT (the Paediatric Research In Emergency Department International Collaborative)* This talk, by Stuart Dalziel, centred around ConSEPT and the management of convulsive status epilepticus.

We were privileged that PREDICT chose to release the results of the ConSEPT trial at DFTB18, almost a year before they were released in press. One of our core aims is cutting the knowledge translation window down from the oft-quoted 17 years. Being able to present exciting new research like this is just one of the ways we hope to do that.

ConSEPT : Stuart Dalziel at DFTB18 - YouTube

*COI – Both Ben and Andy have done or are doing work under the auspices of PREDICT

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

 

 

The post ConSEPT – the reveal: Stuart Dalziel at DFTB18 appeared first on Don't Forget the Bubbles.

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Cite this article as:
DFTB, T. What it meant: Tessa Davis and Shoni Nagel at DFTB19, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.20037

This is a story of friendship and families. It’s a story about one little girl, Libby, and the impact she has had on the world. If you have been friends of DFTB for some time you may have heard parts of her story. As healthcare providers it can be hard to know what to do when a friend or family member comes to us for medical advice. And if the diagnosis is life-changing then it is near-impossible.

What it meant: Shoni Nagel and Tessa Davis at DFTB19 - YouTube

Whilst Tessa and Shoni stood on stage in front of more than 450 people Libby hid outside, waiting for just the right moment to run in. She kept her chaperone (Andy) under control by challenging him to a press-up competition. You can guess who won…  

Press ups with Libby - YouTube

This talk was recorded live at DFTB19 in London, England. With the theme of  “The Journey” we wanted to consider the journeys our patients and their families go on, both metaphorical and literal. DFTB20 will be held in Brisbane, Australia.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

 

The post What it meant: Tessa Davis and Shoni Nagel at DFTB19 appeared first on Don't Forget the Bubbles.

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Given that DFTB18 was held in Melbourne it was important to highlight the work of PREDICT (the Paediatric Research In Emergency Department International Collaborative)* This talk, by Elliot Long, centred around his work on the role of fluids in the septic child.

Following the recent online discussion around the FiSH pilot study and the potential harms of fluid boluses demonstrated in the FEAST trial it would seem apropos to release this talk from DFTB18. We seem to have a knee jerk reaction to give a fluid bolus in septic children but should we?

The FEAST trial was published in 2011 and has had very little impact on what we do in the Western setting. What we think of as a low fluid state – dehydration – is not the same as what our colleagues in Africa would view as sepstic. This is something we will explore at a later date.

So if we can’t rely wholly on our history and our physical exam is often equivocal then what other methods are there? Elliot Long likes to use ultrasound to guide his management.

He looks at the lungs looking for B lines with the linear probe.

Courtesy of The POCUS Atlas

He then looks at the IVC to see if it is plump or underfilled with the phased array probe.

A plethoric IVC courtesy of The POCUS Atlas

And finally he looks at the heart itself, with the phased array probe, to see if it is hyperdynamic.

Courtesy of The POCUS Atlas

Elliot and the PREDICT group recently published some of their work looking at the fluid bolus therapy in septic children. This prospective observational trial looked at the response to a fluid bolus in 41 sick children. Interestingly the mean blood pressure dipped after a fluid bolus and took up to 60 minutes to return to baseline.

Fluid assessment in sepsis : Elliot Long at DFTB18 - YouTube

*COI – Both Ben and Andy have done or are doing work under the auspices of PREDICT

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

 
Cite this article as:
DFTB, T. Fluid assessment in sepsis: Elliot Long at DFTB18, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.19912
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Don't Forget the Bubbles by Sandeep Singh - 1w ago
Cite this article as:
Singh, S. New postsss, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.19987
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With millions upon millions of journal articles being published every year it is impossible to keep up.  Every month we ask some of our friends from PERUKI (Paediatric Emergency Research in UK and Ireland) to point out something that has caught their eye.

Cite this article as:
Leo, G. The 30th Bubble Wrap, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.19891
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Given that DFTB18 was held in Melbourne it was important to highlight the work of PREDICT (the Paediatric Research In Emergency Department International Collaborative)* This talk, by Franz Babl, centred around the management of bronchiolitis and focussed on the recent PARIS trial.

Ben Lawton took a closer look at the trial here and you can see the infographic we developed to go with the paper below.

But what does the expert think? Here is A/Professor Franz Babl from the Melbourne stage.

Selected references

O’Brien S, Borland ML, Cotterell E, Armstrong D, Babl F, Bauert P, Brabyn C, Garside L, Haskell L, Levitt D, McKay N. Australasian bronchiolitis guideline. Journal of paediatrics and child health. 2019 Jan;55(1):42-53.

Haskell L, Tavender EJ, Wilson C, O’Brien S, Babl FE, Borland ML, Cotterell L, Schuster T, Orsini F, Sheridan N, Johnson D. Implementing evidence-based practices in the care of infants with bronchiolitis in Australasian acute care settings: study protocol for a cluster randomised controlled study. BMC pediatrics. 2018 Dec;18(1):218.

Schlapbach LJ, Straney L, Gelbart B, Alexander J, Franklin D, Beca J, Whitty JA, Ganu S, Wilkins B, Slater A, Croston E. Burden of disease and change in practice in critically ill infants with bronchiolitis. European Respiratory Journal. 2017 Jun 1;49(6):1601648.

*COI – Both Ben and Andy have done or are doing work under the auspices of PREDICT

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

Cite this article as:
DFTB, T. High Flow Nasal Cannula Oxygen: Franz Babl at DFTB18, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.19674
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This is an extract of the talk I gave at #DFTB19 highlighting an important research ethos – the full talk will be released via the Don’t Forget the Bubbles at a later date.

The Doctor” is a painting by Luke Fildes and was first exhibited in 1891.

The Doctor exhibited 1891 Sir Luke Fildes 1843-1927 Presented by Sir Henry Tate 1894 http://www.tate.org.uk/art/work/N01522

The artist had lost his son Philip at the age of one and the scenes reflects the admiration that he had had for the doctor who had looked out for him. 

For some the painting may represent a stereotypical view of medicine in the past – the doctor rubbing his chin in a wise fashion, the child prostrate on a make-shift bed. And there is a parent figure in the background, watching on anxiously. 

This painting has had a revival recently despite being over 100 years old. It highlights the triad of care we all know exists in paediatrics – the child, the parents and carers, and ourselves.

This triad has received increased attention recently. The need for child centered care in respect of their engagement and involvement in their care. The need for positive communication with families; we remember the cases where parents haven’t acted as their child’s advocates but forget the vast majority of cases when they have. We so often let parents down when we should have been, not just listening to them, but honestly hearing what they were saying. And most recently the doctors themselves. An understanding of the importance of wellbeing and the shackles of rudeness. 

There is a fourth component, as well. One which perhaps will never get the attention it deserves because it isn’t a visceral part of our clinical care. It’s something we know exists but are quite willing to ignore. It’s something that perhaps has more impact on our practice than we would like to admit. It’s the variability in the actual care or treatment we provide or the fact that it might not be necessary at all.

When I became chair of PERUKI, Paediatric Emergency Research United Kingdom and Ireland, the international sibling of PREDICT and daughter of PERN I’d a personal vision that I would drive the organization forward in delivering ground-breaking new research highlighting novel interventions that would really make a difference to patients. What actually occurred is that I have realised that perhaps PERUKI has an even more important roll. One that does obviously include the need to develop, innovate and implement but one also that highlights where we could, and should do, better. It’s some examples of variation and the need for no treatment I would like to share. 

So this is an original selection of PERUKI members and those who helped us get PERUKI off the ground. I’d like a chance to pay particular tribute to Mark Lyttle at this point who has worked tirelessly at the outset to drive forward many early projects and is consistently named checked by our research partners for his ceaseless enthusiasm at collaborating and engaging. PERUKI took part in a prioritisation process published in 2015 with members putting forward their preferred research agendas and PERUKI publishing the top 20 via a Delphi process.

Number 4 on this list was: what is the best IV medication for Acute Asthma. PERUKI started on this work with essentially a two phase examination of the management of wheeze in March 2013. In the first phase a written questionnaire was undertaken. PERUKI sites responded as departments and 183 consultants responded individually on their wheeze management.

In study 99 (54.1%) use salbutamol as first-line intravenous therapy, 52(28.4%) magnesium sulfate and 27 (14.8%) aminophylline; 87 (47.5%) give these sequentially depending on response and 30 (16.4%) give them concurrently. Overall, 146 (79.8%) continue inhaled bronchodilators while on intravenous therapy.

When commencing on intravenous bronchodilators there were 10 different infusion rates with over 10-fold variation between the lowest and highest.

Everyone tends to have their little foibles about which treatment they prefer. And given the range of phenotypes and genotypes that exist in our wheezy cohort in can’t be the case that there is only going to be one best fit treatment for all patients. But a 10-fold difference probably pushes the bounds of flexibility.

What makes this more interesting is the second study. Also completed at the time (March 2013) was a prospective observational study. Data was screened from all patients presenting with wheeze and a detailed proforma completed for those who received intravenous therapies.Of 3238 children, 101 received intravenous therapies. Intravenous magnesium sulfate (MgSO4) was used in 67 (60.9%), salbutamol in 61 (55.5%) and aminophylline in 52 (47.3%) of cases. 

In 35 cases (31.8%), two drugs were used together, and in 18 cases (16.4%), all three drugs were administered.

More than half used salbutamol as the first-line intravenous agent, while fewer preferred magnesium sulfate or aminophylline, suggesting equipoise regarding which is most efficacious. To investigate this, participants were asked whether they would enrol patients to a randomised controlled trial allocating salbutamol, aminophylline or magnesium sulfate as the first-line intravenous agent, to which 148 (80.9%) responded positively. Asking clinicians who are regularly prescribing acute medications is vital for study design and subsequent implementation of study findings. With all due respect to respiratory paediatricians the question that they may be interested in, or want to explore, may well be completely out of keeping with the practice habits of emergency and acute paediatricians. PERUKI have welcomed increased engagement with our specialty colleagues in the last year and we hope we will reap the benefits of this. 

So a clear example of variation. I feel uncomfortable. Is there any reason to believe this variation has improved 6 years on? We have a challenge as the evidence base is not as strong as we would like. We look to Simon Craig and his work on developing asthma outcomes here – a PERN study I am very proud that PERUKI is part of. 

So what about where we think there is only a small amount of variation (a nationally agreed algorithm for example). DO we need to improve practice and CAN we improve practice? The EcLIPSE study was published a mere month ago and I am proud of the Don’t Forget the Bubbles team  for being part of the process of sharing this information widely. The Eclipse study compared levetiracetam and phenytoin in the treatment of status epilepticus. It was published on exactly the same day as the ConSEPT trial a similar study from our PREDICT friends. The EcLIPSE paper is available open access and there is a Don’t Forget the Bubbles summary. I also recommend the reviews by Justin Morgenstein and Casey Parker 

The primary outcome was time from randomisation to cessation of all visible signs of convulsive activity, defined as cessation of all continuous rhythmic clonic activity, as judged by the treating clinician.

Much debate has centred on what EcLIPSE and ConSEPT showed and at the heart of this is the difference between superiority and non-inferiority.

If these studies do nothing else it will to be to have spread the word about this construct. Because it is really important that people don’t glaze over or think because this terminology is used it’s someones else’s problem to analyse. I think this undue deference to academics probably perpetuates variation in care. I am not saying the theory is easy but neither is managing a sick neonate with congenital heart disease and we completely commit ourselves to doing that. 

Superiority trials aim to demonstrate that one intervention is better than other. The statistics, by convention, dictate that a difference between the interventions needs to be defined. In the case of EcLIPSE because phenytoin stopped status 60% of time and it was felt Levetiracetam may terminate seizures at a 75% rate the statistics calculated that 140 patients would be needed in each group. IF a difference exists this difference is likely to be a difference that is real and not by chance alone.

If they had wanted to show that levetiracetam was only 1% better then 1000s of patients would probably have been needed as if there was no difference by chance it would easily be possible that levetiracetam happened to be 1% better in that cohort of patients. 

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Planning for DFTB20 had begun before the balloons for DFTB19 had barely deflated. Coming back to Australia means warm weather, captivating coffee and another opportunity to catch up with friends old and new.

So so you have something you want to share? Do you want to speak at DFTB20? Do you know someone who would be amazing?

If so then just click this here….

Pitches will close on 1st of August so get them in now! We promise to give you access to two of the most accomplished speaker coaches in the world, Grace Leo and Ross Fisher. We promise the most engaged audience in the world of paediatrics.

Tickets will go on sale on the 1st of November 2019 but why not book your leave now?

*All speakers will need to register to be able to speak.

Cite this article as:
DFTB, T. Speaker pitches for DFTB20 are now open, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.19858
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We were very privileged to be joined in Melbourne by the team from Simulcast. This piece of radio theatre was recorded in front of a live studio audience.

The team discussed, amongst others, these papers…

Ben Symon, Jesse Spurr and Victoria Brazil

Bearman M, Molloy E. Intellectual streaking: The value of teachers exposing minds (and hearts). Medical teacher. 2017 Dec 2;39(12):1284-5.

Ingrassia PL, Franc JM, Carenzo L. A novel simulation competition format as an effective instructional tool in post-graduate medical education. Advances in Simulation. 2018 Dec;3(1):17.

This talk was recorded live at DFTB18 in Melbourne, Australia. With the theme of ‘Science and Story‘ we pushed our speakers to step out of their comfort zones and consider why we do what we do. Caring for children is not just about acquiring the scientific knowhow but also about taking a look beyond a diagnosis or clinical conundrum at the patient and their families.

If you want our podcasts delivered straight to your listening device then subscribe to our iTunes feed or check out the RSS feed. If you are more a fan of the visual medium then subscribe to our YouTube channel. Please embrace the spirit of FOAMed and spread the word.

Cite this article as:
DFTB, T. A Simulcast journal club: Ben, Vic and Jesse at DFTB18, Don't Forget the Bubbles, 2019. Available at:
http://doi.org/10.31440/DFTB.19640

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