Summary Background Phenytoin is the recommended second-line intravenous anticonvulsant for treatment of paediatric convulsive status epilepticus in the UK; however, some evidence suggests that levetiracetam could be an effective and safer alternative. This trial compared the efficacy and safety of phenytoin and levetiracetam for second-line management of paediatric convulsive status epilepticus. Methods This open-label, randomised clinical trial was undertaken at 30 UK emergency departments at secondary and tertiary care centres. Participants aged 6 months to under 18 years, with convulsive status epilepticus requiring second-line treatment, were randomly assigned (1:1) using a computer-generated randomisation schedule to receive levetiracetam (40 mg/kg over 5 min) or phenytoin (20 mg/kg over at least 20 min), stratified by centre. The primary outcome was time from randomisation to cessation of convulsive status epilepticus, analysed in the modified intention-to-treat population (excluding those who did not require second-line treatment after randomisation and those who did not provide consent). This trial is registered with ISRCTN, number ISRCTN22567894. Findings Between July 17, 2015, and April 7, 2018, 1432 patients were assessed for eligibility. After exclusion of ineligible patients, 404 patients were randomly assigned. After exclusion of those who did not require second-line treatment and those who did not consent, 286 randomised participants were treated and had available data: 152 allocated to levetiracetam, and 134 to phenytoin. Convulsive status epilepticus was terminated in 106 (70%) children in the levetiracetam group and in 86 (64%) in the phenytoin group. Median time from randomisation to cessation of convulsive status epilepticus was 35 min (IQR 20 to not assessable) in the levetiracetam group and 45 min (24 to not assessable) in the phenytoin group (hazard ratio 1·20, 95% CI 0·91–1·60; p=0·20). One participant who received levetiracetam followed by phenytoin died as a result of catastrophic cerebral oedema unrelated to either treatment. One participant who received phenytoin had serious adverse reactions related to study treatment (hypotension considered to be immediately life-threatening [a serious adverse reaction] and increased focal seizures and decreased consciousness considered to be medically significant [a suspected unexpected serious adverse reaction]). Interpretation Although levetiracetam was not significantly superior to phenytoin, the results, together with previously reported safety profiles and comparative ease of administration of levetiracetam, suggest it could be an appropriate alternative to phenytoin as the first-choice, second-line anticonvulsant in the treatment of paediatric convulsive status epilepticus. Funding National Institute for Health Research Health Technology Assessment programme.

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Abdominal USS performed by paediatric radiologists is an accurate method of assessing abdominal injuries. However, CT scanning can assess certain abnormalities such as pancreatic or duodenal injuries and small amounts of free intraperitoneal air more accurately. The importance of serial clinical examination must not be overlooked.

Background Point-of-care testing (POCT) is diagnostic testing performed at or near to the site of the patient. Understanding the current capacity, and scope, of POCT in this setting is essential in order to respond to new research evidence which may lead to wide implementation. Methods A cross-sectional online survey study of POCT use was conducted between 6th January and 2nd February 2020 on behalf of two United Kingdom (UK) and Ireland-based paediatric research networks (Paediatric Emergency Research UK and Ireland, and General and Adolescent Paediatric Research UK and Ireland). Results In total 91/109 (83.5%) sites responded, with some respondents providing details for multiple units on their site based on network membership (139 units in total). The most commonly performed POCT were blood sugar (137/139; 98.6%), urinalysis (134/139; 96.4%) and blood gas analysis (132/139; 95%). The use of POCT for Influenza/Respiratory Syncytial Virus (RSV) (45/139; 32.4%, 41/139; 29.5%), C-Reactive Protein (CRP) (13/139; 9.4%), Procalcitonin (PCT) (2/139; 1.4%) and Group A Streptococcus (5/139; 3.6%) and was relatively low. Obstacles to the introduction of new POCT included resources and infrastructure to support test performance and quality assurance. Conclusion This survey demonstrates significant consensus in POCT practice in the UK and Ireland but highlights specific inequity in newer biomarkers, some which do not have support from national guidance. A clear strategy to overcome the key obstacles of funding, evidence base, and standardising variation will be essential if there is a drive toward increasing implementation of POCT.

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IntroductionThe adolescent population comprises a significant proportion of attendances to the ED. Despite adolescent patients reporting lower levels of healthcare satisfaction compared with other age groups, their opinions are under-represented in existing literature. This prospective study investigated adolescents’ expectations and preferences regarding the ED service.MethodsA questionnaire designed by the investigators was distributed to children aged 12–16 years over a 6-month period in 2015 at two EDs in the UK. The questionnaire explored themes such as same-sex and similar-age areas, staff communication and environment. Interviews based on the questionnaire template were also conducted and guardians were permitted to accompany the participant. Verbal informed consent was obtained from both the young person and their guardian to participate in the study.ResultsThere were 254 respondents, which represented 8.8% of adolescent attendances in the study period. ‘Cleanliness’ was rated the most important factor within the ED setting with 94.8% of respondents selecting 4 or 5 on a 5-point Likert scale. This was followed by ‘feeling comfortable’, ‘clear explanation’ and ‘staff communication’ (91.2%, 90.8% and 90.4% rating these 4 or 5, respectively). However, when participants were asked to select a single most important factor, being ‘seen quickly’ was selected most frequently (95/206, 46.1%). ‘Entertainment’ was regarded the least important with only 17.0% selecting 4 or 5 on the Likert scale. Preference for being treated in an adult ED compared with a child ED increased with age.ConclusionsBeing ‘seen quickly’ was considered the single most important factor by adolescent patients in the ED. Notably, ‘cleanliness’ and aspects of communication also rated highly, with ‘entertainment’ regarded as least important. The additional insight into the healthcare preferences of the adolescent population provides a platform on which the future ED services can be tailored to the needs of young people.