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A young lady was ventilated on intensive care for a prolonged period with NMDA receptor encephalitis. She had undergone steroid, immunoglobulin, and plasmapheresis with no evidence of recovery. Her main management issue was the control of severe orofacial and limb dyskinesia. Large doses of sedating agents had been used to control the dystonia but were ineffective, unless she was fully anaesthetised. The introduction of a ketamine infusion was associated with a dramatic improvement in her symptoms such that it was possible to remove her tracheostomy two days after commencement. She was discharged shortly after that and is making a good recovery. The successful use of ketamine has not previously been described in this context, and we hope this case report will provide some insight into the management of this rare but serious condition.

Background Acute pancreatitis is a common, yet complex, emergency surgical presentation. Multiple guidelines exist and management can vary significantly. The aim of this first UK, multicentre, prospective cohort study was to assess the variation in management of acute pancreatitis to guide resource planning and optimize treatment. Methods All patients aged greater than or equal to 18 years presenting with acute pancreatitis, as per the Atlanta criteria, from March to April 2021 were eligible for inclusion and followed up for 30 days. Anonymized data were uploaded to a secure electronic database in line with local governance approvals. Results A total of 113 hospitals contributed data on 2580 patients, with an equal sex distribution and a mean age of 57 years. The aetiology was gallstones in 50.6 per cent, with idiopathic the next most common (22.4 per cent). In addition to the 7.6 per cent with a diagnosis of chronic pancreatitis, 20.1 per cent of patients had a previous episode of acute pancreatitis. One in 20 patients were classed as having severe pancreatitis, as per the Atlanta criteria. The overall mortality rate was 2.3 per cent at 30 days, but rose to one in three in the severe group. Predictors of death included male sex, increased age, and frailty; previous acute pancreatitis and gallstones as aetiologies were protective. Smoking status and body mass index did not affect death. Conclusion Most patients presenting with acute pancreatitis have a mild, self-limiting disease. Rates of patients with idiopathic pancreatitis are high. Recurrent attacks of pancreatitis are common, but are likely to have reduced risk of death on subsequent admissions.

Figure 2 Written Feedback on simulation courseword cloud summaries Overwhelmingly, their suggestions for improvement was to have more, regular simulation sessions exploring different paediatric scenarios. Conclusion Our results reflect a significant self-reported positive impact of paediatric emergency simulation education on medical students.We aim to further develop these sessions for medical students, to help improve their preparedness in recognising and managing acutely unwell children and young people. REFERENCE

BackgroundHead injury is a common presenting complaint to emergency departments and can generate clinical concern regarding non accidental injury (NAI) in young children. Clinicians are wary of exposing young children to unnecessary radiation but must balance this risk with their duty to protect the child and recognise abuse.ObjectiveTo review all radiological imaging for trauma related head injuries in under-2 year olds with the aim of establishing the incidence of non-accidental injury and identify associated features that may aid clinical decision making.DesignA single-centre retrospective note review was conducted over a 3 year period (01/01/12 – 01/01/2015) of children<2 years of age who presented to a tertiary paediatric hospital (RHSC, Glasgow) and received cranial imaging. Cases were identified using the PACS reporting system.Results75 cases were identified as trauma related neuroimaging over the study period and were subject to a detailed case note review. Median age was 39 weeks. There was a male predominance of 65%. All 75 patients underwent CT head as their primary mode of trauma imaging.Abnormal findings were reported in 79% with the most common finding being unilateral parietal skull fracture. 44% of those with positive findings on CT underwent a skeletal survey and 36% had ophthalmology review. 31% had a social work strategy meeting prior to discharge.17% of patients with positive findings on CT head were deemed to have sustained their injury secondary to abuse. None of these injuries were witnessed. Median age was 16 weeks. 70% of inflicted injuries had a complex skull fracture compared to 18% for those deemed accidental. 20% of the NAI group were previously known to social work compared to 3% in the accidental group.ConclusionCT is the modality of choice for suspected skull fracture in RHSC, Glasgow. Younger age, unwitnessed injury, existing social work support and complex skull fracture were all associated more commonly with abusive injuries in this 3 year review. Our data has contributed to a larger UK study aiming to determine national variation in practice and deriving a clinical decision making tool to exclude/diagnose NAI as the cause of skull fracture.

0-16yo), place of diagnosis (local hospital), and new diagnosis. Results 21 patients were identified within the database; four were excluded due to diagnosis in other country or lack of notes. 9 females and 8 males were included, with a mean age of 8 years and a median duration of presenting symptoms of 21 days. 82% were referred to the paediatric emergency department by their general practitioner (GP). 82% reported polyuria, 76% reported polydipsia, 29% reported fatigue and weight loss, with other presenting symptoms including nocturia and high capillary blood glucose measured at home. 76% had a family history of diabetes or autoimmune disease. 82% presented with hyperglycaemia, and 18% in diabetic ketoacidosis. Mean presenting capillary blood glucose was 24 mmol/L with a mean HbA1c of 106 mmol/mol. Only 2 patients (12%) had urine dipstick results documented on their hospital discharge summary. 16 subjects had a new diagnosis of type 1 diabetes and 1 had a new diagnosis of type 2 diabetes. Compared to previous data from 2013, in which 50% of patients had a delay in diagnosis, 3 patients (18%) had delayed diagnosis of diabetes. All of this group were seen prior to diagnosis by their GP, with a median duration of delay of 3 days. Conclusion Delay in diagnosis of diabetes in children appears to have reduced in the past 5 years in the local area. However, practice must continue to improve to prevent unacceptable delay. This requires education to improve symptom recognition, of both local healthcare professionals, and also of adult patients with autoimmune disease, in view of the high incidence of diabetes in children with a family history.

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Conclusions There had been some initial hesitancy to use new system and availability of probes in all delivery areas. Simulation sessions for staff training and provision of spare probes in the emergency resuscitation kits have facilitated use. Hypothermia during transport is an identified area to improve.