Hey Reader,

Welcome to another edition of Bursting The Bubbles, DTFB's newsletter with some top tips, evidence highlights, and the best dad jokes.

This week we look at c-spine imaging and radiation, papilloedema, and being an LGBTQIA+ ally.

Let's do it...

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WEEKLY BUBBLE WRAP: RADIATION EXPOSURE AND C-SPINE INJURIES

What’s It About?

This single-centre study looked at reducing radiation exposure in the under-8 population when assessing for traumatic CSI (cervical spine injury) by modifying the imaging protocol within their CSI guideline. Instead of imaging the cervical spine, the guideline advised focused imaging of C1-C4. Previous evidence suggests that most CSI in children aged eight and younger occurs between the occiput and C4.

Undergoing a CT scan as a young child increases your lifetime risk of radiation-attributable cancer, especially to radiosensitive tissue such as the thyroid. This study aimed to see if a modified screening tool could minimise radiation exposure without compromising the ability to detect cervical spine injury.

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This retrospective cohort study compared pre- and post-guideline outcomes. An MDT committee developed the guideline at a level 2 paediatric trauma centre in the USA. Imaging was recommended for patients with high-risk pre-disposing conditions, concerning clinical findings or high-impact injuries. If imaging was recommended, they started with plain X-rays. However, any child going for a CT head would also undergo paediatric spinal protocol imaging of C1-C4. Spinal specialists were then consulted if any spinal injury was identified or if the physical examination remained abnormal despite normal imaging. In these patients, MRIs of the full spine were requested at the surgeon’s discretion.

All paediatric trauma patients aged eight or under-screened for CSI at the trauma centre between July 2017 and December 2020 were included. 726 patients were screened and split into cohorts of 273 pre-guideline and 453 after implementation. There were no significant differences between the two cohorts. Mean age and ISS scores were similar between the groups.

Full cervical spine CTs were more common before the guideline (22% pre vs 11% post). CT scans of C1-C4 were more common after implementation. MRI utilisation was similar in both groups (4% vs 4.9%). In total, eleven patients had cervical spine injuries. Ten were injuries between C1-C4 – nine were ligamentous injuries picked up on MRI, and one was C1-C2 subluxation detected on CT scan. One patient with persistent neck pain had a C7-T1 interspinous ligament injury picked up on MRI after a normal CT scan of the whole cervical spine.

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Why Does It Matter?

Although CSI is a rare consequence of blunt trauma, delayed or missed diagnoses can have dire consequences, with mortality as high as 48% in children under eight. Whilst MRI may be more diagnostically accurate (CT is still the most useful initial screening tool to look for the most severe injuries), it is often less readily available, is time-consuming and may require sedation. Children with CSI may have other multiorgan injuries, including to the brain; timely diagnosis is paramount in paediatric trauma patients.

The C spine of children aged eight or younger is anatomically immature and, therefore, susceptible to different injury patterns than that of adults or older children. We also must consider the increased risk of radiation-induced cancers in children who undergo CT, especially in young children going through a crucial time in their development.

Whilst its results are encouraging, they must be interpreted cautiously. This was a single-centre study, with only a small number of diagnosed CSIs. Some of the patients included had undergone imaging before enrolment, and the quality of scans was variable. The use of collars for immobilisation is still included in the study protocol (which we have moved away from in the UK).

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Clinically Relevant Bottom Line:

This study has certainly highlighted potential areas for improvement compared with the current protocols. There may be a place for more targeted cervical spine imaging in the paediatric population- to reduce the radiation dose. Before guidance can change, more work is needed to determine true injury rates and the number of missed injuries.

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Reviewed by: Isobel Lane. Read the full Bubble Wrap here.

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TOPIC OF THE WEEK: BE AN LGBTQIA+ YOUNG PERSON'S ALLY

If you’re reading this, you’re probably an advocate for LGBT+ rights. You might even have an NHS or HSE rainbow badge. Great! But wearing a badge is only one step towards being an ally. The wearer must feel confident that they will treat the young person with respect and that they’ll know what to do if a young person discloses to them. The wearer may be the first person a young person has ever felt confident enough to open up to about how they feel; it may be one of the most important moments of that LGBT+ young person’s life.

So, how can you be an LGBT+ young person’s ally?

You don’t need a rainbow badge (of course you don’t) to be an LGBT+ young person’s ally. But there are a few things that will help you on your way.

First, you need to understand what LGBT+ means.

Let’s start with some definitions.

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+: inclusive of all identities (queer, questioning, intersex, asexual, pansexual amongst others), regardless of how people define themselves.

There are some key definitions of sexual and gender orientation and expression. Let’s go through them:

Sexual orientation is a description of who we are attracted to romantically or sexually, such as lesbian, gay, bisexual, asexual, heterosexual.

Gender orientation describes an internal sense of being male, female, neither or both, a psychological sense of who we are and who we feel we are.

Transgender: a person’s gender identity is different from the gender they were assigned at birth.

Cisgender: a person’s gender identity matches the gender they were assigned at birth.

Non-binary: a person who doesn’t identify as exclusively male or exclusively female.

Gender expression is a description of how we portray ourselves to the world; how we act, speak, talk and dress. It ranges from feminine, through androgynous, to masculine.

These definitions are explained perfectly by the Genderbread person.

OK. So you know a bit of the lingo. What can you do to be an LGBT+ young person’s ally?

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Don’t make assumptions

We live in a heteronormative environment (where being heterosexual is considered the norm) and people often make heteronormative assumptions. This means we may make an unconscious assumption that heterosexual is ‘normal’ without even realizing we’re doing it. The example on HSEland’s LGBT+ Awareness and Inclusion e-learning module is a classic example of this…

Katy is an 8-year-old girl who has been brought to the emergency department by her two mums, Jill and Freda. She’s called into triage and, after inviting them to sit down, the triage nurse asks, “Which one of you is Katy’s mum?” Jill replies by saying, “Actually, we’re a family with two mothers.”

The triage nurse made a heteronormative assumption here. A more inclusive approach would have been for the triage nurse to ask Katy to introduce each of the ladies accompanying her. But, until we can shake heteronormative assumptions, it can be easily done; if you do make a heteronormative assumption, apologize and move on. And make an effort not to make a similar mistake next time.

Another assumption that’s often made is about a young person’s sexual identity based on their sexual behaviour.

Suzy is a 15-year-old girl who attends the emergency department with abdominal pain and dysuria. Her urine sample is dipped – no nitrites or leucocytes, but her beta-HCG is positive. She’s pregnant. With this information in hand, you go in and, after some gentle questioning (you’re pretty good at building rapport), you ask her how old her boyfriend is. She looks at you with disdain and replies, “I don’t have a boyfriend.” Blustering a little, you ask whether she and her boyfriend have broken up. “I’ve never had a boyfriend,” she replies.

Suzy is attracted sexually and romantically to girls and has a girlfriend called Melissa. And you’ve just lost her trust by assuming she was straight. Adolescent lesbian and bisexual girls are also at risk of unintended pregnancies and acquiring sexually transmitted infections.

Yet another assumption people make is cis-normativity, the belief, or unconscious assumption, that that it is ‘normal’ to be cis-gendered. It’s explained all too well by Emily, an 11-year-old transgender girl in the Mermaid’s #IfIHadAVoice video.

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Use inclusive language

It can feel artificial to start with, but try and break the heteronormative barrier and ask a young person what their chosen gender or pronouns are.

If you accidentally misgender someone, apologize and correct yourself. We often don’t know what name or pronouns someone would like us to use, and it’s safest to assume nothing and ask (and I mean ask everyone, because you will be caught out if you don’t), “How would you like us to record your details in the medical record?”

What about sexual orientation? A sensitive way to ask a young person about their sexual identity is to ask if they have a partner or if they’re in a relationship. If they don’t have a partner, ask them if they’re attracted to boys, girls, either or neither.

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Reassure the young person their sexual or gender identity will be kept confidential

Before you start taking a history, explain to a young person that anything you discuss will be kept confidential and private, between the young person and the team looking after them, but if you discuss anything really serious, like suicide or that someone was abusing them, then you’ll come up with a plan together to get the help needed. But, and this is an important but, even if there’s something that you need to seek help for, you’ll keep their sexual or gender identity confidential if this is what they want – this is private to them and you shouldn’t be outing the young person against their wishes.

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Be an ally

Knowing the different LGBT+ terms isn’t important. What is important is listening with respect, not making assumptions and creating a safe space for discussion. An ally supports equal rights for LGBT+ people and let’s face it, we’re in healthcare because we want to help people. Healthcare is for everyone.

You may be the first person an LGBT+ young person meets in their acute healthcare. You may be the person they confide in. Their interaction with you may be one of the most important moments of their life.

Read more about this here.

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HIGHLIGHT: PAPILLOEDEMA

If we do see papilloedema in children in ED (and let's be honest I think many of us might struggle to accurately identify it...), does it mean something worrying is going on?

From the limited evidence available, many children with optic disc swelling do not have papilloedema. It is even less likely if they are boys and are asymptomatic.
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The most likely diagnosis in children with papilloedema is idiopathic intracranial hypertension. However, some more sinister diagnoses (tumour, hydrocephalus, infection) can occur.
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A sinister diagnosis is very unlikely in an asymptomatic child.

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If there is papilloedema, what is the chance it is due to a sinister pathology requiring immediate diagnosis and treatment?

Cavuoto found that 2% of the overall study population was diagnosed with a brain tumour. There was no other pathology requiring immediate treatment.

The most common diagnosis, affecting approximately 60% of those with papilloedema, was idiopathic intracranial hypertension. Here there is raised intracranial pressure without a space-occupying lesion or hydrocephalus and with normal cerebrospinal fluid (CSF) composition. It does not usually need emergency treatment to relieve symptoms and preserve visual function.

Two smaller retrospective studies (Maheswaran et al. 2020 and Hyde et al. 2019) describe 23% and 13% of children with papilloedema as having significant pathology – an intracranial tumour, hydrocephalus, or intracranial infection.

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Read more about papilloedema here.

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EVENT OF THE WEEK

Last month was National Cleft and craniofacial abnormalities awareness month.

It's all of our responsibility to check for a cleft palate. This is simple to do, and there's clear RCPCH guidance about this.

Read more about how to do it here.

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TIP OF THE WEEK

Post-drowning prophylactic antibiotics have not been shown to be helpful though they are sometimes prescribed after immersion in contaminated water. Read more here.

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JOKE OF THE WEEK

Why did the bicycle fall over?

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It was two-tyred!

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That's it for this week, Reader.

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Remember, your work makes a difference in the lives of paediatric patients every day.

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Stay tuned for next week's edition of Bursting The Bubble.

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From Tessa (on behalf of Team DFTB)

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