Category Archives: Emergency medicine

Martha’s Law

13yr old Martha Mills died in 2021 at King’s College Hospital, London, of sepsis after pancreatic trauma (fell off bike in Snowdonia). The family went to the local minor injuries unit, where they were reassured. She continued to have severe pain however, then vomiting – so they went to the nearest hospital. She was admitted to the ward, then ICU, before being transferred by helicopter to King’s College London (1 of 3 specialist centres for pancreatic injury in the UK).

“We are so lucky to be here”, writes the mum.

She was NG fed, a peritoneal drain inserted. She started mobilising after 2 weeks. Then she developed fever and diarrhoea – started antibiotics. “The consultants swooped in, and were ostentatiously deferred to by the junior doctors.

“They were chatty, assertive, grand.”

Martha then started oozing from drip sites and peritoneal drain site. A scan showed small pericardial effusion. She had a persistent fever – and it was the start of a bank holiday weekend.

Consultant went home after morning round. Martha’s mum raised her concern about septic shock but was told “it’s just a normal infection”. She was told not to look up things on the internet – “you’ll only worry yourself”.

When she developed low BP and tachycardia, then widespread rash, it was diagnosed as a drug reaction.

““Trust the doctors – they know what they’re doing,” said the nurses.

The consultant was contacted to discuss worsening PEWS – did not come in – no change in management was made. The consultant phoned PICU (routine) but gave limited info – advised against review “to avoid parental anxiety”. The night shift junior did not review. Martha was drinking copiously.

At 0545 she had a seizure, at which point people started arriving and things seemed to happen – she was moved to PICU, intubated and then moved to Great Ormond Street hospital for ECMO. She died 4 days before her birthday.


  • Mum is editor at Guardian newspaper
  • Nothing to do with insufficient resources, overstretched doctors/nurses, or cuts, or a health service under strain
  • Consultants dismissive and arrogant
  • Juniors “performing” competence
  • No one expressed concern, even if they had it
  • Lack of note keeping
  • Lack of consultant presence at weekend
  • All doctors mentioned at inquest were men

Mum’s advice to parents

  1. Our trust in doctors should have limits. Plenty of clinicians prone to arrogance and complacency.
  2. However indebted you feel to the NHS, don’t be afraid to challenge decisions if you have good reason to.
  3. Remember most of the doctors in hospitals are just [sic] training. Don’t be afraid to ask how long a clinician has been qualified. Junior doctors are often green and trying to stay composed to impress their superiors.
  4. Make sure, if you can, that a single consultant has overall responsibility: we all know that if you’re answerable for something, you try harder.
  5. Google like crazy.


September 2023 Riya Harani dies from invasive Group A streptococcus and influenza B. Seen in hospital the day before. Junior doctor diagnosed a virus and discharged her with advice to take over the counter painkillers and info re: management of sore throat. Consultant not involved. At inquest, coroner says ““I think it highly likely that if it had been open to Riya’s family to seek a second opinion at that point, they would have done so without hesitation.”

UK Minister for health has said they will progress with the right to urgent second opinions across the health service.

Second Opinions

Right to second opinion already in Good Medical Practice: “In providing clinical care, you must respect the patient’s right to seek a second opinion”. But not traditionally associated with acute care and no detail otherwise.

Seeking a second opinion is more common in:

  • women, middle-age patients,
  • more educated patients, higher income or socioeconomic status,
  • chronic conditions,
  • living in central urban areas.

Motivation is to seek to gain more information, or reassurance. Potential major impact on patient outcomes in up to 58% of cases. 


Condition Help (Pittsburgh, 2000s), Call 4 concern (Royal Berkshire) – hospital hotline to call rapid response team to bedside. Ryan’s rule (Queensland) is state-wide number for review of medical care.

But evidence of benefit sparse. Tends to be pain management and communication breakdown rather than acute deterioration. 18% of patients generated nearly half of all calls to Condition Help (in 41.4% of cases, a change in care was made).

International Society for Rapid Response systems includes family trigger system as one measure of effectiveness. 

“The recurring problems of hierarchy, arrogance and poor culture have not been tackled despite decades of effort… It is not the job of patients and families to wait around for healthcare providers to sort out their culture.” [(Helen Haskell, BMJ 2023)]

Such systems do not address problems of overcrowded wards, lack of beds, delayed assessments, poor nurse:patient ratios etc… Perhaps don’t appreciate informal senior discussions that happen all the time. Potential for delays in appropriate treatment if process of getting second opinion interferes with management?

“I’d like to imagine a world in which Martha was transferred to intensive care in time and her life was saved.

In this parallel universe, I talk endlessly about the doctors and nurses who helped herI go on a fundraising walk for the hospital.

Bright and determined girl as she was, Martha aces all her exams, goes to university, has a career and children.

She visits us at weekends and we recall those distant weeks when she was in hospital.”

Mrs Mills

Variceal bleeding

Due to portal hypertension from chronic liver disease.

Potential for large losses – may need local major haemorrhage protocol (FFP, platelets etc) – typically if blood loss >150mls/min, or else 20% blood volume loss in <1 hour (normal blood volume is 80ml/kg).

In adults, they try not to transfuse above 80 – thought that excessive transfusion may increase bleeding.

Terlipressin preferred to octreotide – from age 12. IV injection every 4 hours. No evidence for Tranexamic acid!

NG tube may cause more trauma…

In adults, Glasgow-Blatchford score used. Authors are Oliver and Mary Blatchford (couple?) – he was actually in Paisley at the time…

Stroke in children

Rare but happens.


Can be due to arterial or venous occlusion.  50:50 in kids cf adults (80% infarct). Haemorrhagic can be due to rupture into infarct.

Presents with focal signs, headache, seizures most commonly. Else dysphasia, vomiting!, confusion. Fever! Acute signs often lacking or fluctuant cf history!  FAST criteria only 78% sensitive. 

NIH stroke severity scale has paeds version. 

Risk factors


Cardiac (esp surgery, right to left shunt)

Sickle cell – esp anaemia, acute chest syndrome, HbS or HbS/Beta thal


Liver/kidney disease (secondary prothrombotic tendency)

VZV within 1yr, enteroviruses, HIV.

Vasculitis – Moya Moya (peaks at 5-9yr else adulthood), SLE, other

Cocaine, glue.

Marfans, homocysteinuria, Fabry’s disease, Neurofibromatosis

Cancer, radiotherapy



High flow O2, 10ml/kg saline 

Imaging within 1hr. 

BP – avoid high and low? Cf adults

Monitor for RICP

Treat with aspirin.


  • CTA/MRA at time of CT/MRI
  • Echo
  • (Transcranial doppler in sickle cell- via temporal bony window)
  • Hbopathy screen
  • Cholesterol
  • Lupus anticoagulant, Anti cardiolipin ab (ACLA), consider beta 2GP1
  • Homocysteine
  • Alpha galactosidase
  • Lipoprotein A – a kind of LDL but induces vascular inflammation, so a marker for CVS disease 
[RCPCH guideline May 2017]


See SVT.

Adenosine 150mcg/kg? 12yr 3mg

Broad complex SVT – just treat as VT.


Remove oxygen tubing for shocks unless closed circuit.

Stand clear – look at top/middle/bottom!

IM/IN ketamine plus sedation for synchronised shock.

Synchronised shocks are 1 then 2 J/kg.

Sync button needs pressed for each shock – most machines immediately reset. Press and hold – needs time to sync and give shock.


UK Resuscitation council updates guidelines from time to time.

See also anaphylaxis (now 2 guidelines, basic and refractory) and arrhythmia.

Atropine not part of guideline – neonates 10mcg/kg (no minimum). Else 20mcg/kg min 100mcg. 

Out of hospital – Shout for help AND ask for an AED.  Sudden OOH collapse likely to be cardiac, even in a child – don’t wait till after rescuer breaths!

Compressions 100-120.min for both infants and children. One third depth of chest – 4cm infant, 5 child (6 adult). 1 finger breadth above xiphisternum to avoid organs. 

40% blood volume might be lost before hypotension appears…

5th centile for systolic BP is 70 at 1yr, 80 at 10, 90 at 15yr. 

Haemothorax might be picked up in B but don’t manage until C!

C – compartments of body incl long bones. 1:1 RCC:FFP

TXA – bolus, remember 2nd dose (or double bolus). 

Log roll can be missed if suspected spinal unless penetrating back wound suspected (or found on absorbent surface…)

ATMIST – age, time, 

Parents need a senior person who understands!

CT head might be better done at trauma centre…


Muscle breakdown with release of products into blood stream that can cause acute renal failure.

Typically occurs with crush injuries, sometimes seen with extreme endurance sports.

Can be infectious.

Recurrent seen with fatty acid oxidation disorders and Lipin 1 mutations.

Lipin 1 mutations

Autosomal recessive – heterozygotes may have exercise induced muscle symptoms or be prone to drug induced myopathy.

Basal CK high but spikes to over 100 000 with decompensation (infection, exercise, anaesthetic).

Treat crises with carbohydrates/intralipid.


Children are small adults, when it comes to trauma!

Mortality jumps when airway management instituted more than 45 mins after 999 call. (NICE) Mortality actually rare with isolated head (7%) and abdominal (20%) trauma. But jumps to 50% for multiple sites.

Beware head impact apnoea.

Collars not required as part of immobilisation in children. Cx spine trauma v rare. Manual in line stabilisation best if necessary. Extrication maybe?

Triage tool highlights who needs to go to trauma centre eg mangled limbs, penetrating or open trauma, mechanisms eg ejection from vehicle.  But always clinical judgement.

If “hot critical” then decide on transfer to tertiary centre within 8 minutes. Airway, catastrophic haemorrhage and move.

C-ABC is catastrophic haemorrhage first.

Access above and below diaphragm if possible. Blood first line if bleeding. 10ml/kg aliquots. 1:1:1 packed cells, FFP and platelets as able.

Tranexamic acid dose 15ml/kg (same as paracetamol!). See major haemorrhage protocol. No role for permissive hypotension in children.

Avoid over resuscitation with crystalloid.

Pelvic binder problematic if moves. Fixes greater trochanters and public symphysis.

AVPU – but specify pain response!

Head injury: 3% saline preferred. Aim for high MAP, with inotropes if necessary. GGC has guideline. Adrenaline preferred.

Agitated kid – persevere with getting them into scanner without anaesthetic! In Wishaw, induction best in theatre but would then need to go in lift!  Limited expertise with waking them up! Discuss with Scotstar, maybe move, maybe tube.

Log roll 90% out, 20% in? Conrad 2012

Traumatic cardiac arrest: in adults, evidence for aggressive treatment of reversible causes. Consensus is for bundle of simultaneous interventions (not all necessary for every case), prioritised ahead of CPR!

  • Haemorrhage control
  • ETT or equivalent
  • Bilat finger thoracostomies
  • Rapid volume replacement with warmed blood NOT thoracotomy or inotropes. Persistent low ETCO2 is poor prognostic sign.

Even if death declared out of hospital, should be admitted for after care.

NAI audit – 5.2% rate of suspected child abuse. 75% under 1 yr. Often major trauma, often severe brain injury.

Major Incident

Workload should be spread out. Over 12 should go to adults (unless lots of adults too). Walking wounded to non trauma centres. Try not to separate children from injured parents – who worst affected?


Usually due to renal failure. Causes arrhythmia and death…


  • Slow injection of calcium – note calcium chloride and gluconate both available so potential for confusion. Dose is 0.11 mmol/kg, to be given over 5–10 minutes, maximum 4.5 mmol (0.11 mmol/kg is equivalent to 0.5 mL/kg of calcium gluconate 10%). Repeat as necessary if ECG changes do not improve.
  • Bicarbonate indicated if hyperkalaemia due to acidosis or renal failure. 
  • Insulin/dextrose – 10ml/kg 10% dextrose (so 5x usual dose for hypoglycaemia!), plus 0.1u/kg insulin (max 10 units), give over 5 mins. Likely peak action at 30 mins.
  • Dialysis.
  • Hydrocortisone if suspected Addisons. 
  • ECG monitoring
  • Repeated salbutamol nebs

Frusemide and calcium resonium only for asymptomatic!


January 2022 – safety alert from MHRA/CMO regarding deaths where there was a delay in providing emergency transfusion.

Should be agreed criteria for rapid concessionary release of blood products.

One issue is Autoimmune haemolytic anaemia, where the presence of red cell antibodies will complicate cross matching (11% mortality!).

Another issue highlighted is failure to give Prothrombin complex concentrate to reverse warfarin (and some other anticoagulants) where severe or limb/sight threatening bleeding.