G92(P) Paediatric cardiac murmur guideline for the children’s emergency department

Abstract

Aim To evaluate current practice in requesting salicylate levels in children presenting with intentional overdose. Background Intentional overdose is a common presentation in children's emergency departments but the pattern of medications taken has changed over time. Over the last two decades use of aspirin (salicylate) has markedly reduced since recognition of Reye's Syndrome in children. Toxbase and NPIS advise salicylate levels are not required unless there is admission of ingestion, symptoms of salicylate toxicity or in the unconscious patient. It was noted that it remains common practice to check salicylate levels in children with intentional overdose. Methods A retrospective review of all children presenting with intentional overdose at a busy two site acute trust. Case note and blood results review of all children coded as poisoning between July -December 2012, excluding children with accidental overdose. Results There were 59 episodes of intentional overdose with 53 females and 6 males. The average age was 14yrs (11 -16yrs). 73% (43) of the patients were asymptomatic. The most common drug taken was paracetamol (46%), followed by ibuprofen (20%) and cocodamol (11%). Only 2 patients (3%) admitted taking salicylate. The majority of initial blood tests were taken in the emergency department (71%). 83% (49) had salicylate levels measured and only 4% (2) had abnormal levels. Both of these patients had admitted salicylate ingestion. No patients who denied salicylate ingestion were found to have raised levels. Salicylate levels were deemed appropriate and useful in 4 (8%) patients due to history or symptoms. It was also observed that there was frequent requesting of a wide range of unnecessary blood tests including CK, FBC and CRP.Conclusion There is considerable over testing of salicylate levels in children with intentional overdose. Our results found the test appropriate in only 4 (8%) patients. The laboratory test itself is relatively cheap however, in combination with other unnecessary tests, the cumulative cost is significant. We advise improved education as to the indications for salicylate levels as part of aiming to reduce unnecessary investigations and costs in children's emergency department. Aim To develop a paediatric cardiac murmur guideline for a Children's emergency department (CED), following mismanagement of 2 cases of heart murmurs in children. Currently there is no national guideline in place. Methods Electronic databases Medline, Embase, Cochrane Cinahl, Psycinfo, Amed, British nursing index, DARE and CENTRAL were searched using title/abstract terms and subject headings: heart/cardio/cardia/murmur/sound AND diagnosis/ assessment/evaluation/examination. Results were limited to children aged 0-18 years and no limitations placed on date or language. The results were exported on to Mendeley workstation and analysed. G92(P)PAEDIATRICAbstract G92(P) Figure 1 Neonatal murmur algorithm Abstracts A38Arch Dis Child 2015;100(Suppl 3):A1-A288

The 6 to 8-week check

“…In general, a murmur is more likely to be pathological if it is loud, diastolic or continuous, heard over a wide area, or associated with other abnormal features, while, a soft systolic murmur at the left sternal edge in an otherwise normal infant may be benign (Frank and Jacobe, 2011). Any murmur associated with a heave, weak or absent pulses, central cyanosis, respiratory distress, poor feeding or failure to thrive requires prompt expert evaluation (Venugopalan and Ranaweera, 2015). If in any doubt, discuss with a paediatric cardiologist and refer as appropriate.…”