BACKGROUND:Whether treatment with balanced crystalloid fluid leads to better outcomes than 0.9% saline in children treated for septic shock is debated. METHODS:In this pragmatic clinical trial conducted at 47 emergency departments in five countries, patients (2 months to <18 years of age) with suspected septic shock and abnormal perfusion were randomly assigned to receive fluid resuscitation with either balanced fluid or 0.9% saline for up to 48 hours. The primary outcome was a major adverse kidney event (a composite of death, new renal-replacement therapy, or persistent kidney dysfunction) at 30 days after enrollment or hospital discharge, whichever occurred first. RESULTS:Of 9041 enrolled patients, 277 (6.1%) in the balanced-fluid group and 282 (6.2%) in the 0.9%-saline group withdrew from the trial, leaving 4235 and 4247 patients, respectively, for analysis. A primary-outcome event occurred in 137 patients (3.4%) in the balanced-fluid group and in 124 (3.0%) in the 0.9%-saline group (difference, 0.4 percentage points; 95% confidence interval [CI], -0.5 to 1.3; risk ratio, 1.10; 95% CI, 0.88 to 1.40; P = 0.85). The median number of hospital-free days during 28 days after enrollment was 23 (interquartile range, 19 to 25) in both groups. Hyperchloremia occurred in 868 patients (31.4%) in the balanced-fluid group and in 1383 (49.0%) in the 0.9%-saline group; hypernatremia in 52 (1.8%) and 89 (3.1%), respectively; and hyperlactatemia in 260 (19.8%) and 228 (16.7%). No differences in other safety outcomes or adverse events were seen. CONCLUSIONS:Among children treated for septic shock, no significant difference was seen in the incidence of death, new renal-replacement therapy, or persistent kidney dysfunction when fluid resuscitation was administered with balanced fluid as compared with 0.9% saline. (Funded by Eunice Kennedy Shriver National Institute of Child Health and Human Development and others; PRoMPT BOLUS ClinicalTrials.gov number, NCT04102371.).

Background:Paediatric sepsis epidemiology is unclear due to variability in case ascertainment. We describe the epidemiology of community acquired sepsis in Australian and New Zealand children using the Phoenix sepsis criteria. Methods:Prospective observational study conducted in 11 hospitals through the Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network from April 2021 to December 2023. Children aged 0-<18 years with suspected sepsis were included. Demographic information, therapies administered, and outcomes were collected, and the Phoenix sepsis criteria were applied. Findings:Of 822,072 children assessed, 6232 (0.8%) children had suspected sepsis and 306 (<0.1%) met the Phoenix sepsis criteria. Children who met the Phoenix sepsis criteria had higher rates of intensive care unit admission (245/306; 80.1% vs 1080/6232; 17.3%), vasoactive infusion (144/306; 47.1% vs 179/6232; 2.9%) mechanical ventilation (146/306; 47.7% vs 251/6232; 4.0%), and extracorporeal life support (12/306; 3.9% vs 13/6232; 0.2%) compared to the overall cohort. Intensive care unit and hospital length of stay were longer for those meeting Phoenix sepsis criteria than for the overall cohort (median 48.4 h vs 79.8 h and 69.7 h vs 189.8 h, respectively). Overall, 87/6232 (1.4%) patients died within 90 days, 42/306 (13.7%) of whom met Phoenix sepsis criteria. Interpretation:Hospitalisation for suspected sepsis was relatively infrequent. The Phoenix sepsis criteria identified children with more severe illness and worse outcomes, but underestimated the overall burden of sepsis. Funding:The National Health and Medical Research Council, the Medical Research Futures Fund, The Royal Children's Hospital Foundation, and the Victorian Government.

Importance:The novel Phoenix Sepsis Score and sepsis criteria were derived and validated using a multicountry dataset and proposed as a new definition for sepsis in children. Objective:To externally validate the Phoenix Sepsis Score and sepsis criteria in a cohort of children hospitalized with suspected community-acquired sepsis. Design, Setting, and Participants:This diagnostic study used data from the multicenter, multicountry Sepsis Epidemiology in Australian and New Zealand Emergency Departments (SENTINEL) study, collected from 2021 to 2023 and including 90-day follow-up. Children admitted to the hospital through 11 emergency departments in Australia and New Zealand and treated with parenteral antibiotics with either (1) a provisional diagnosis of sepsis or (2) treatment for sepsis (intravenous fluid bolus to treat poor perfusion) were included. Exposure:Development of organ dysfunction over the first 24 hours of hospitalization. Main Outcomes and Measures:The main outcomes were (1) in-hospital mortality and (2) death or requirement for extracorporeal life support (ECLS) within 72 hours of hospitalization. Results:A total of 6232 children were included in the analysis, with a median (IQR) age of 2.1 (0.3-7.1) years, 3386 (54.1%) male, in-hospital mortality of 60 (1.0%), and death or ECLS within 72 hours in 36 (0.6%). In this population, the worst Phoenix Sepsis Score calculated over the first 24 hours of hospitalization had an area under the precision recall curve of 0.17 (95% CI, 0.07-0.28) for predicting in-hospital mortality and 0.23 (95% CI, 0.11-0.36) for predicting death or ECLS within 72 hours. Overall, 306 children (4.9%) met the Phoenix sepsis criteria, of whom 33 (10.8%) died in the hospital (nearly half of the total number who died) and 28 (9.2%) died or required ECLS within 72 hours. The Phoenix sepsis criteria had a sensitivity of 55.0% (95% CI, 41.6%-67.9%) and positive predictive value (PPV) of 10.8% (95% CI, 7.6%-14.9%) for in-hospital mortality and sensitivity of 77.8% (95% CI, 60.8%-89.9%) and PPV of 9.2% (95% CI, 6.2%-13.0%) for death or ECLS within 72 hours. Coagulation data for the calculation of the Phoenix Sepsis Score were missing in more than 85% of children. Conclusions and Relevance:In this multicenter diagnostic study of children hospitalized with suspected sepsis, the Phoenix Sepsis Score and sepsis criteria had similar performance to the original derivation and validation cohorts. The small proportion of children meeting Phoenix sepsis criteria, missingness of data, timing of application, and lack of sensitivity for in-hospital mortality limit the clinical utility of the criteria.

INTRODUCTION:Paediatric cervical spine injury (CSI) is uncommon but can have devastating consequences. Many children, however, present to emergency departments (EDs) for the assessment of possible CSI. While imaging can be used to determine the presence of injuries, these tests are not without risks and costs, including exposure to radiation and associated life-time cancer risks. Clinical decision rules (CDRs) to guide imaging decisions exist, although two of the existing rules, the National Emergency X-Radiography Low Risk Criteria and the Canadian C-Spine Rule (CCR), focus on adults and a newly developed paediatric rule from the Pediatric Emergency Care Applied Research Network (PECARN) is yet to be externally validated. This study aims to externally validate these three CDRs in children. METHODS AND ANALYSIS:This is a multicentre prospective observational study of children younger than 16 years presenting with possible CSI following blunt trauma to 1 of 14 EDs across Australia, New Zealand and Singapore. Data will be collected on presenting features (history, injury mechanism, physical examination findings) and management (diagnostic imaging, admission, interventions, outcomes). The performance accuracy (sensitivity, specificity, negative and positive predictive values) of three existing CDRs in identifying children with study-defined CSIs and the specific CDR defined outcomes will be determined, along with multiple secondary outcomes including CSI epidemiology, investigations and management of possible CSI. ETHICS AND DISSEMINATION:Ethics approval for the study was received from the Royal Children's Hospital Melbourne Human Research Ethics Committee in Australia (HREC/69436/RCHM-2020) with additional approvals from the New Zealand Human and Disability Ethics Committee and the SingHealth Centralised Institutional Review Board. Findings will be disseminated through peer-reviewed publications and future management guidelines. TRIAL REGISTRATION NUMBER:Registration with the Australian New Zealand Clinical Trials Registry prior to the commencement of participant recruitment (ACTRN12621001050842). 50% of expected patients have been enrolled to date.

Background:Vasoactive agents are a critical supportive therapy for children with sepsis. We describe the choice and use patterns of vasoactive agents in children with sepsis. Methods:Prospective observational study conducted in 11 hospitals in Australia and New Zealand through the Paediatric Research in Emergency Departments International Collaborative (PREDICT) Network from April 2021 to December 2023. Children aged 0-<18 years with suspected sepsis were included. Children admitted to hospital and treated with parenteral antibiotics and either 1) a provisional diagnosis of sepsis, and/or 2) treatment for suspected sepsis (fluid bolus to treat poor perfusion). The frequency and sequence of use of vasoactive agents, and contributors to the choice of initial vasoactive were collected. Findings:6232 children with suspected sepsis were included; median age of 2.1 years (IQR 0.3-7.1 years), in-hospital mortality of 60 (1.0%), in whom a subset of 306 (4.9%) met Phoenix sepsis criteria. Vasoactive agents were used in 179 (2.9%) children overall and in 144 (45.8%) of those meeting Phoenix sepsis criteria. The most used first, second, and third-line vasoactive agents were adrenaline (90/179; 50.3%), noradrenaline (49/91; 53.8%), and vasopressin (16/40; 40.0%). When comparing noradrenaline vs adrenaline as first line agents, increasing age was associated with preferential use of noradrenaline (RR 1.06, 95% CI 1.03-1.09; p < 0.001). Interpretation:Children with suspected community acquired sepsis rarely received treatment with vasoactive agents. Adrenaline and noradrenaline were the most used agents, though there was substantial variation in their use and sequencing. Funding:This study is funded in part by a National Health and Medical Research Council (NHMRC) Medical Research Future Fund grant (GNT1190814). The full list of funders is presented at the end of the paper.

OBJECTIVE:Clinical practice guidelines (CPGs) are an important tool for the management of children with sepsis. The quality, consistency and concordance of Australian and New Zealand (ANZ) childhood sepsis CPGs with the Australian Commission on Safety and Quality in Healthcare (ACSQHC) sepsis clinical care standards and international sepsis guidelines is unclear. METHODS:We accessed childhood sepsis CPGs for all ANZ states and territories through Paediatric Research in Emergency Departments International Collaborative members. The guidelines were assessed for quality using the AGREE-II instrument. Consistency between CPG treatment recommendations was assessed, as was concordance with the ACSQHC sepsis clinical care standards and international sepsis guidelines. RESULTS:Overall, eight CPGs were identified and assessed. CPGs used a narrative and pathway format, with those using both having the highest quality overall. CPG quality was highest for description of scope and clarity of presentation, and lowest for editorial independence. Consistency between guidelines for initial treatment recommendations was poor, with substantial variation in the choice and urgency of empiric antimicrobial administration; the choice, volume and urgency of fluid resuscitation; and the choice of first-line vasoactive agent. Most CPGs were concordant with time-critical components of the ACSQHC sepsis clinical care standard, although few addressed post-acute care. Concordance with international sepsis guidelines was poor. CONCLUSION:Childhood sepsis CPGs in current use in ANZ are of variable quality and lack consistency with key treatment recommendations. CPGs are concordant with the ACSQHC care standard, but not with international sepsis guidelines. A bi-national sepsis CPG may reduce unnecessary variation in care.

Introduction Sepsis affects 25.2 million children per year globally and causes 3.4 million deaths, with an annual cost of hospitalisation in the USA of US$7.3 billion. Despite being common, severe and expensive, therapies and outcomes from sepsis have not substantially changed in decades. Variable case definitions, lack of a reference standard for diagnosis and broad spectrum of disease hamper efforts to evaluate therapies that may improve sepsis outcomes. This landscape analysis of community-acquired childhood sepsis in Australia and New Zealand will characterise the burden of disease, including incidence, severity, outcomes and cost. Sepsis diagnostic criteria and risk stratification tools will be prospectively evaluated. Sepsis therapies, quality of care, parental awareness and understanding of sepsis and parent-reported outcome measures will be described. Understanding these aspects of sepsis care is fundamental for the design and conduct of interventional trials to improve childhood sepsis outcomes.Methods and analysis This prospective observational study will include children up to 18 years of age presenting to 12 emergency departments with suspected sepsis within the Paediatric Research in Emergency Departments International Collaborative network in Australia and New Zealand. Presenting characteristics, management and outcomes will be collected. These will include vital signs, serum biomarkers, clinician assessment of severity of disease, intravenous fluid administration for the first 24 hours of hospitalisation, organ support therapies delivered, antimicrobial use, microbiological diagnoses, hospital and intensive care unit length-of-stay, mortality censored at hospital discharge or 30 days from enrolment (whichever comes first) and parent-reported outcomes 90 days from enrolment. We will use these data to determine sepsis epidemiology based on existing and novel diagnostic criteria. We will also validate existing and novel sepsis risk stratification criteria, characterise antimicrobial stewardship, guideline adherence, cost and report parental awareness and understanding of sepsis and parent-reported outcome measures.Ethics and dissemination Ethics approval was received from the Royal Children’s Hospital of Melbourne, Australia Human Research Ethics Committee (HREC/69948/RCHM-2021). This included incorporated informed consent for follow-up. The findings will be disseminated in a peer-reviewed journal and at academic conferences.Trial registration number ACTRN12621000920897; Pre-results.

Aim The purpose of this study was to evaluate whether pre‐recorded video‐based lectures (VBLs) covering a range of paediatric topics are an acceptable means of providing ongoing education for consultant and trainee paediatricians in Australia. Methods Previous participants (paediatric consultants and junior medical officers) of a neurology outreach teleconference programme offered by a paediatric neurologist between 2017 and 2020 were invited to participate in a multi‐specialty pre‐recorded video‐based education programme. Acceptability was explored by assessing relevance, likelihood of utilising VBL's in the future, uptake and learning activity preferences. The impact of VBLs on confidence, currency and practice was also explored. Additional data including topics of interest, preferred video format, duration, viewing method and frequency of delivery were captured, to better understand participant preferences to inform future efforts. Results A total of 135 consented; 116 returned baseline; 94 returned follow‐up surveys. Preferred learning activities included a live/interactive component. Videos were considered relevant. Preferences for pre‐recorded videos improved from ninth to sixth most preferred learning activity post‐intervention. VBL convenience and accessibility were valued. Practice was altered in: approach to management, use of treatments, confidence in decision‐making, and discussion with families and patients. The average view duration was 16 min. Longer videos yielded slightly lower audience retention rates. For future offerings, the majority endorsed a preference for a ‘mixed’ video format and duration of 20–40 min, offered monthly. Conclusion Video‐based medical education is an appealing and sustainable alternative, given the convenience of unrestricted accessibility, in meeting ongoing learning needs of Australian paediatricians and trainees.

BACKGROUND:Children rarely experience critical illness, resulting in low exposure of emergency physicians (EPs) to critical procedures. Our primary objective was to describe senior EP confidence, most recent performance, and/or supervision of critical nonairway procedures. Secondary objectives were to compare responses between those who work exclusively in PEM and those who do not and to determine whether confidence changed for selected procedures according to increasing patient age.METHODS:Survey of senior EPs working in 96 emergency departments (EDs) affiliated with the Pediatric Emergency Research Networks. Questions assessed training, performance, supervision, and confidence in 11 nonairway critical procedures, including cardiopulmonary resuscitation (CPR), vascular access, chest decompression, and cardiac procedures.RESULTS:Of 2446 physicians, 1503 (61%) responded to the survey. Within the previous year, only CPR and insertion of an intraosseous needle had been performed by at least 50% of respondents: over 20% had performed defibrillation/direct current cardioversion. More than 50% of respondents had never performed or supervised ED thoracotomy, pericardiocentesis, venous cutdown, or transcutaneous pacing. Self-reported confidence was high for all patient age groups for CPR, needle thoracocentesis, tube thoracostomy, intraosseous needle insertion, and defibrillation/DC cardioversion. Confidence levels increased with increasing patient age for central venous and arterial line insertion. Respondents working exclusively in PEM were more likely to report being at least somewhat confident in defibrillation/DC cardioversion, intraosseous needle insertion, and central venous line insertion in particular age groups; however, they were less likely to be at least somewhat confident in ED thoracotomy and transcutaneous pacing.CONCLUSIONS:Cardiopulmonary resuscitation and intraosseous needle insertion were the only critical nonairway procedures performed by at least half of EPs within the previous year. Confidence was higher for these procedures, and needle and tube thoracostomy. These data may inform the development of continuing medical education activities to maintain pediatric procedural skills for emergency physicians.

AIM:Penicillin allergy labels are frequently encountered in children and are associated with significant harms. Most children are falsely labelled and can safely tolerate a penicillin but delabelling strategies are underutilised and paediatric-specific resources are lacking. The aim of this study was to evaluate an allergy assessment tool for children in hospital.METHODS:We evaluated a paediatric-adapted penicillin allergy assessment tool, using an online survey of clinicians in a tertiary paediatric hospital, with 10 hypothetical potential penicillin allergy or adverse reaction cases (including non-allergy reactions). For each case, respondents were asked to use the tool to assign a reaction phenotype and recommend management. We determined the tool's sensitivity, specificity and acceptability to end users.RESULTS:We evaluated 30 complete survey responses from senior and junior medical staff, nurses and pharmacists. The tool's overall sensitivity was 80.7% (95% confidence interval (CI) 74.2-87.1%) for assigning the correct reaction phenotype and 85.3% (95% CI 79.4-91.3%) for appropriate management. The tool had high sensitivity for identifying immediate hypersensitivity reactions at 95.6% (95% CI 90.2-100%). Most respondents agreed or strongly agreed that they would use the tool in their practice (22/30, 73.3%).CONCLUSION:This survey evaluated a paediatric-adapted penicillin allergy assessment tool in a tertiary paediatric hospital among multidisciplinary clinician groups. The tool performed well overall and had high safety in identifying immediate hypersensitivity reactions. Further research to support implementation of allergy assessment and delabelling programmes among children is required.

Background: Airway management procedures are critical for emergency medicine (EM) physicians, but rarely performed skills in pediatric patients. Worldwide experience with respect to frequency and confidence in performing airway management skills has not been previously described. Objectives: Our aims were 1) to determine the frequency with which emergency medicine physicians perform airway procedures including: bag-mask ventilation (BMV), endotracheal intubation (ETI), laryngeal mask airway (LMA) insertion, tracheostomy tube change (TTC), and surgical airways, and 2) to investigate predictors of procedural confidence regarding advanced airway management in children. Methods: A web-based survey of senior emergency physicians was distributed through the six research networks associated with Pediatric Emergency Research Network (PERN). Senior physician was defined as anyone working without direct supervision at any point in a 24-h cycle. Physicians were queried regarding their most recent clinical experience perforrning or supervising airway procedures, as well as with hands on practice time or procedural teaching. Reponses were dichotomized to within the last year, or >= 1 year. Confidence was assessed using a Likert scale for each procedure, with results for ETI and LMA stratified by age. Response levels were dichotomized to "not confident" or "confident." Multivariate regression models were used to assess relevant associations. Results: 1602 of 2446 (65%) eligible clinicians at 96 PERN sites responded. In the previous year, 1297 (85%) physicians reported having performed bag-mask ventilation, 900 (59%) had performed intubation, 248 (17%) had placed a laryngeal mask airway, 348 (23%) had changed a tracheostomy tube, and 18 (1%) had performed a surgical airway. Of respondents, 13% of physicians reported the opportunity to supervise but not provide ETI, 5% for LMA and 5% for BMV. The percentage of physicians reporting "confidence" in performing each procedure was: BMV (95%) TTC (43%), and surgical airway (16%). Clinician confidence in ETT and LMA varied by patient age. Supervision of an airway procedure was the strongest predictor of procedural confidence across airway procedures. Conclusion: BMV and ETI were the most commonly performed pediatric airway procedures by emergency medicine physicians, and surgical airways are very infrequent. Supervising airway procedures may serve to maintain procedural confidence for physicians despite infrequent opportunities as the primary proceduralist. (C) 2020 Elsevier Inc. All rights reserved.

AimThe aim was to evaluate an educational video in educating doctors on the key messages and follow‐up pathways following a first afebrile seizure presentation. A multidisciplinary expert team developed the video (http://www.pennsw.org.au/families/resources/first-seizure-pack-and-video) based on available evidence and best‐practice. It contains a role‐play between the parent/child and physician. It addresses: key messages to impart following a first seizure, seizure first aid, safety messages including necessary precautions post‐discharge, contents of the First Seizure Pack for families, follow‐up pathway and issues for discussion with the paediatrician at a later appointment.MethodsPaediatric/Emergency department (ED) trainees across three Australian sites were recruited during terms 1 and 2, 2019. A repeated measures design was used. Multilevel modelling analyses were performed. The primary outcome was clinician knowledge. Secondary outcomes were confidence in answering questions and counselling families. Qualitative data on the utility, strengths and weaknesses of the video were evaluated.ResultsA total of 127 participants consented, one withdrew prior to commencing. A total of 126 baseline surveys, 115 follow‐up surveys and 45 1‐month follow‐up surveys were returned. Viewing the video significantly improved knowledge of key messages at immediate follow‐up (P < 0.001) and 1‐month follow‐up (P = 0.048). Likewise, confidence was significantly improved; 96.5% of responders found the video useful, 90.3% were likely to use the resource in the future and 82% would change their approach to counselling. Most liked aspects of the resource were clarity/conciseness of the information (n = 70) and comprehensiveness (n = 38).ConclusionThis education video significantly improved clinician knowledge and confidence in counselling families following first seizure.

Objectives To investigate patient-level factors predictive for computed tomography of the brain (CTB) use and abnormality in head injured children in Australia and New Zealand. Methods Retrospective data from tertiary, urban/suburban and regional/rural EDs including factors predictive for CTB use and abnormality. Results Of 3072 children at 31 EDs, 212 (6.9%) had a CTB scan, of which 66 (31%) were abnormal. Increasing age, serious mechanisms of injury and decreasing Glasgow Coma Score were predictive for ordering CTB. Decreasing age was predictive for CTB abnormalities. Other factors were not. Conclusion Patient-level drivers of CTB use in children in Australia and New Zealand are consistent with international data.

Aim Croup is a major cause of emergency department (ED) presentations, but there remains a paucity of evidence to guide clinical decision-making around which patients require admission. We aimed to describe the clinical characteristics, management and outcomes of patients presenting to the ED with croup and to identify characteristics associated with a need for further intervention. Methods We conducted a retrospective cohort study of all patients presenting to the ED of a tertiary paediatric hospital with croup between 2011 and 2016. Patients were included if they received two doses of nebulised adrenaline in the ED and were aged between 6 months and 6 years. Baseline characteristics, vital signs 2 h post-second dose of nebulised adrenaline, management and outcomes were recorded. Results A total of 5045 patients presented to ED with croup during the study period, 112 of whom received two doses of nebulised adrenaline within the ED. Of these patients, half were discharged home and half admitted to hospital. None of the discharged patients went on to require further intervention, and 19% of admitted patients received further interventions. Age and history of a chronic medical condition were associated with a need for further intervention. Of the vital signs, abnormal heart rate, fever and stridor were associated with a need for further intervention. Conclusions Only 19% of patients admitted following two doses of nebulised adrenaline in the ED required further interventions. Older patients without a chronic medical condition who have a normal heart rate, temperature and no stridor may be suitable for outpatient management.

Background Phenytoin is the current standard of care for second-line treatment of paediatric convulsive status epilepticus after failure of first-line benzodiazepines, but is only effective in 60% of cases and is associated with considerable adverse effects. A newer anticonvulsant, levetiracetam, can be given more quickly, is potentially more efficacious, and has a more tolerable adverse effect profile. We aimed to determine whether phenytoin or levetiracetam is the superior second-line treatment for paediatric convulsive status epilepticus. Methods ConSEPT was an open-label, multicentre, randomised controlled trial conducted in 13 emergency departments in Australia and New Zealand. Children aged between 3 months and 16 years, with convulsive status epilepticus that failed first-line benzodiazepine treatment, were randomly assigned (1: 1) using a computer-generated permuted block (block sizes 2 and 4) randomisation sequence, stratified by site and age (= 5 years, > 5 years), to receive 20 mg/kg phenytoin (intravenous or intraosseous infusion over 20 min) or 40 mg/kg levetiracetam (intravenous or intraosseous infusion over 5 min). The primary outcome was clinical cessation of seizure activity 5 min after the completion of infusion of the study drug. Analysis was by intention to treat. This trial is registered with the Australian and New Zealand Clinical Trials Registry, number ACTRN12615000129583. Findings Between March 19, 2015, and Nov 29, 2017, 639 children presented to participating emergency departments with convulsive status epilepticus; 127 were missed, and 278 did not meet eligibility criteria. The parents of one child declined to give consent, leaving 233 children (114 assigned to phenytoin and 119 assigned to levetiracetam) in the intention-to-treat population. Clinical cessation of seizure activity 5 min after completion of infusion of study drug occurred in 68 (60%) patients in the phenytoin group and 60 (50%) patients in the levetiracetam group (risk difference -9 center dot 2% [95% CI -21 center dot 9 to 3 center dot 5]; p= 0 center dot 16). One participant in the phenytoin group died at 27 days because of haemorrhagic encephalitis; this death was not thought to be due to the study drug. There were no other serious adverse events. Interpretation Levetiracetam is not superior to phenytoin for second-line management of paediatric convulsive status epilepticus. Funding Health Research Council of New Zealand, A+ Trust, Emergency Medicine Foundation, Townsville Hospital Private Practice Fund, Eric Ormond Baker Charitable Fund, and Princess Margaret Hospital Foundation. Copyright (c) 2019 Elsevier Ltd. All rights reserved.

The Paediatric Acute Care Conference is an annual conference organised by APLS Australia to advance paediatric acute care topics for clinicians in pre-hospital medicine, EDs, acute paediatrics, intensive care and anaesthesia. The Conference 2017 was held at Surfers Paradise, Queensland. We provide a summary of some of the presentations.

Objective To describe senior paediatric emergency clinician perspectives on the optimal frequency of and preferred modalities for practising critical paediatric procedures. Methods Multicentre multicountry cross-sectional survey of senior paediatric emergency clinicians working in 96 EDs affiliated with the Pediatric Emergency Research Network. Results 1332/2446 (54%) clinicians provided information on suggested frequency of practice and preferred learning modalities for 18 critical procedures. Yearly practice was recommended for six procedures (bag valve mask ventilation, cardiopulmonary resuscitation (CPR), endotracheal intubation, laryngeal mask airway insertion, defibrillation/direct current (DC) cardioversion and intraosseous needle insertion) by at least 80% of respondents. 16 procedures were recommended for yearly practice by at least 50% of respondents. Two procedures (venous cutdown and ED thoracotomy) had yearly practice recommended by <40% of respondents. Simulation was the preferred learning modality for CPR, bag valve mask ventilation, DC cardioversion and transcutaneous pacing. Practice in alternative clinical settings (eg, the operating room) was the preferred learning modality for endotracheal intubation and laryngeal mask insertion. Use of models/mannequins for isolated procedural training was the preferred learning modality for all other invasive procedures. Free-text responses suggested the utility of cadaver labs and animal labs for more invasive procedures (thoracotomy, intercostal catheter insertion, open surgical airways, venous cutdown and pericardiocentesis). Conclusions Paediatric ED clinicians suggest that most paediatric critical procedures should be practised at least annually. The preferred learning modality depends on the skill practised; alternative clinical settings are thought to be most useful for standard airway manoeuvres, while simulation-based experiential learning is applicable for most other procedures.

AimTo assess adherence to the Iocal guideline (LG) for the management of fever in infants under 3 months and whether the application of a risk‐stratified protocol (RSP) to this population would miss any serious bacterial infections (SBI) compared to current practice (CP) and LG.MethodsAll presentations to the authors’ Emergency Department of infants 0–3 months with fever from 1 July 2015 to 28 April 2016 were included (n = 219), along with a detailed analysis of CP. The initial history, examination and pathology results were applied to the LG and RSP to assess what changes in management would occur. The primary end point was a missed SBI, with secondary outcomes measuring the number of invasive procedures performed, antibiotics prescribed and admissions.ResultsAdherence to the LG was 83% with three missed SBIs. Strict adherence would have resulted in eight missed SBIs. This indicates that both warranted and unwarranted variation exists in current clinical practice. Application of the RSP showed no missed SBIs but, compared to CP, indicates a statistically significant increase in admissions and full septic screens (admissions 95% vs. 83%, P < 0.05; full septic screens 82% vs. 72%, P < 0.05). Chest X‐rays were infrequently requested (10%) and the validity of use in this group warrants further study.ConclusionAn ad hoc risk‐stratified practice already exists at the authors’ institution, and application of an RSP did not miss any SBIs. Adoption and implementation of a formal RSP is currently being formulated.

AimThe aetiology and clinical course of Bell's palsy may be different in paediatric and adult patients. There is no randomised placebo controlled trial (RCT) to show effectiveness of prednisolone for Bell's palsy in children. The aim of the study was to assess current practice in paediatric Bell's palsy in Australia and New Zealand Emergency Departments (ED) and determine the feasibility of conducting a multicentre RCT within the Paediatric Research in Emergency Departments International Collaborative (PREDICT).MethodsA retrospective analysis of ED medical records of children less than 18 years diagnosed with Bell's palsy between 1 January, 2012 and 31 December, 2013 was performed. Potential participants were identified from ED information systems using Bell's palsy related search terms. Repeat presentations during the same illness were excluded but relapses were not. Data on presentation, diagnosis and management were entered into an online data base (REDCap).ResultsThree hundred and twenty-three presentations were included from 14 PREDICT sites. Mean age at presentation was 9.0 (SD 5.0) years with 184 (57.0%) females. Most (238, 73.7%) presented to ED within 72 h of symptoms, 168 (52.0%) had seen a doctor prior. In ED, 218 (67.5%) were treated with steroids. Prednisolone was usually prescribed for 9 days at around 1 mg/kg/day, with tapering in 35.7%.ConclusionTreatment of Bell's palsy in children presenting to Australasian EDs is varied. Prednisolone is commonly used in Australasian EDs, despite lack of high-level paediatric evidence. The study findings confirm the feasibility of an RCT of prednisolone for Bell's palsy in children.

Convulsive status epilepticus (CSE) is the most common life-threatening childhood neurological emergency. Despite this, there is a lack of high quality evidence supporting medication use after first line benzodiazepines, with current treatment protocols based solely on non-experimental evidence and expert opinion. The current standard of care, phenytoin, is only 60% effective, and associated with considerable adverse effects. A newer anti-convulsant, levetiracetam, can be given faster, is potentially more efficacious, with a more tolerable side effect profile. The primary aim of the study presented in this protocol is to determine whether intravenous (IV) levetiracetam or IV phenytoin is the better second line treatment for the emergency management of CSE in children.