29 - Emergency Paediatrics 1 Flashcards
What is the last parameter to go in a child during shock?
BP (Cap Refill better than BP)
Why do we have to contact PICU if having to give more than 40ml/kg to children?
Risk of pulmonary oedema so need intubation and inotropes
If newborn has CRP>10 what do you have to investigate?
Need a LP as 33% of infections in newborns are meningitis
FULL SEPTIC SCREEN!
What is the most common cause of paediatric cardio-respiratory arrest?
Respiratory problem causing prolonged hypoxaemia resulting in cardiac arrest
e.g birth asphyxia, inhalation of foreign body, acute asthma or bronchiolitis
Unlikely to be primary cardiac cause
What is the process of neonatal life support?
How do you do paediatric basic life support in hospital? (WATCH VIDEO VERY IMPORTANT)
https://www.youtube.com/watch?time_continue=132&v=IzbnQ3JJsFY&feature=emb_title
Safety, Stimulate, Shout for Help/Ask for 2222!!!!!!!!!!!!!!
- Check then open airway (neutral if <1, sniffing if older) and check breathing for 10 seconds
- Give 5 rescue breaths with BVM
- If no spontaneous breathing, HR<60 or no central pulse after 10 secs start next step
- 15 chest compressions to 2 breaths for 4 cycles/1 minute and get help if none yet
What pulse should you feel in paeds BLS?
Children: carotid, brachial or femoral artery
Infants: brachial artery
When are chest compressions started in paediatric BLS and what is the technique for this?
No sign of life, no pulse, HR<60
Compression of the lower half of the sternum by around 1/3 of its depth with full recoil. 100-120/min
Infants: hand encircling if 2 rescuers, 2 finger if 1 rescuer
Children: heel of their hand over the lower half of the sternum
How do you give rescue breaths out of the hospital?
Infant: cover nose and mouth with rescuer mouth
Child: pinch nose and breath in mouth
What are correctable causes of cardiorespiratory arrest?
What are some causes of cardiac and respiratory arrest?
Think of any cause of respiratory distress
- Sepsis
- Pneumonia
- Asthma
- Raised ICP
- Foreign body
- Aspiration
- Seizure
- Neonatal apnea
When should you pause in paediatric ALS to check for shockable rhythms?
After every 2 minutes of CPR
When do we need immediate vascular access via IO in children?
- Cardiorespiratory arrest
- Severe burns
- Prolonged status epilepticus
- Hypovolaemic and septic shock
What are some contraindications to IO access?
Best site is proximal tibia (can also do distal tibia or distal femur)
- Osteoporosis
- Osteogenesis imperfecta
- Infection or fracture at the site of insertion
If a child is choking, should you clear their airway?
- If can be retrieved by pincer grip yes
- Do not perform a blind finger sweep as can push foreign body further into airway
How do you manage an infant that is choking?
- Encourage coughing
- 5 back blows checking after each one if foreign body has been removed
- 5 chest thrusts
- If unconscious CPR
How do you manage a child that is choking?
- Encourage coughing
- 5 back blows checking after each
- 5 abdominal thrusts (fist with hand over top) checking after each
- If unconscious CPR
What is shock and the four causes of this?
Life threatening condition caused by the systemic failure of the circulatory system, causing inadequate perfusion of major organs
- Hypovolemic
- Obstructive – obstruction of blood flow to and from the heart
- Cardiogenic – pump failure
- Distributive
- Septic
What are three signs of compensated shock?
ALWAYS CONSIDER IF CHANGE IN MENTAL STATE
- Tachycardia to increase cardiac output
- Redistribution of blood flow to increase perfusion of more important organs at the expense of others (e.g. skin and kidneys)
- Tachypnoea to reduce anaerobic respiration and reduce lactic acidosis formation
- Reduced urine output
- Increased cap refill
What are two causes of distributive shock?
Sepsis and Anaphylaxis
Systemic vasodilation due to loss of sympathetic tone because of the release of vasodilators
What are some causes of hypovolaemic shock?
- Dehydration e.g. diarrhoea, vomiting, burns, inadequate feeding in infants, or diuresis in DKA
- Third spacing e.g sepsis and anaphylaxis, the release of inflammatory mediators increases the permeability of capillaries, leading to fluid in the capillaries moving to the interstitial space
- Haemorrhage.
What are some causes of cariogenic shock?
Very rare in children and poor prognosis
Viral myocarditis or acute deterioration of heart failure secondary to CHD
Should be suspected if not responding to fluid therapy and BP remains low and/or is demonstrating signs of pulmonary overload (tachypnoea, respiratory distress, hepatomegaly)
What are some causes of obstructive shock?
Least common shock in children, obstruction to the outflow of blood from the heart itself or the great vessels
Coarctation of the aorta, cardiac tamponade, tension pneumothorax or massive pulmonary embolism
Shock is an emergency so management and investigations should occur simultaneously. What investigations should be done?
- Lactate and blood gases: look for ischaemia
- Creatinine: look for AKI
- U+Es: see if electrolytes off due to diarrhoea etc
- FBC, CRP, Blood cultures: if suspect sepsis
What is the management for shock?
- A to E
- 20ml/kg bolus with saline. Get IO line if IV difficult
- Blood products/inotropes if not responding to fluids e.g IV adrenaline ordopamine
- Escalate to PICU
- Treat underlying cause e.g sepsis 6
In children with suspected cardiogenic shock, be cautious with fluid resuscitation and start with 5ml/kg fluid boluses
What are some complications of shock?
What is the most common cause of shock in children and how does it appear when it becomes decompensated?
Sepsis
- Hypotension
- Decreased O2 sats
- Chest/abdominal pain
- Weak, thready pulse
- Cold, grey or mottled skin
- Decreased body temperature
What are some causes of dehydration in children?
Inadequate intake or Excessive Loss
Diarrhoea and Vomiting most common cause of dehydration
What questions can you ask in the history to determine the level of dehydration in a child?
- How many episodes of D+V and how much fluid in each?
- Is the child still eating and drinking, how much?
- Is the chill still urinating, is it concentrated or dilute?
According to NICE what are some symptoms and signs of dehydration and shock?
Think about dry mouth/tongue and no tears
Reduced urine output
What are some red flags for dehydration in children?
- Appears unwell or deteriorating
- Altered responsiveness
- Sunken eyes
- Reduced skin turgor
- Tachycardia
- Tachypnoea
How is dehydration managed in children?
- Start fluid chart
- PO or IV fluids
How much PO fluid is given to correct dehydration?
Oral Rehydration Solution
50ml/kg + Maintenance Fluids over 4 hours
Which dehydrated children need IV fluids?
20ml/kg 0.9% Sodium Chloride (10ml/kg if DKA) if shocked
- Shock is suspected or confirmed
- A child with red flag symptoms or signs
- A child persistently vomits the oral rehydration solution
If a child is in shock you give 20ml/kg bolus. If a child is not in shock, what amount of IV fluids should you give them?
Fluid Deficit + Maintenance
Weight (kg) x % replacement x 10. This is given over 48 hours
The % replacement (also known as % dehydration) should be assumed to be 10%, if dehydrated.
What monitoring needs to be done when correcting dehydration in children?
MONITOR THROUGHOUT 48 HOURS OF CORRECTION
- U+Es: to determine if need electrolytes added to fluids
- Plaasma glucose
Significant ongoing losses through, for example, vomiting or diarrhoea should be documented on the patient’s fluid balance chart and replaced in addition to fluid deficit correction
How can you work out percentage dehydration in children?
Percentage weight loss
If no previous weight loss available and clinically dehydrated use 10%
What is the definition of sepsis and septic shock?
Dysregulated immune response to an infection that leads to life threatening organ damage
When cardiovascular compromise this is shock
SIRS (systemic inflammatory response) in the presence of infection
What is the pathophysiology of septic shock?
Causative pathogens recognised by macrophages, lymphocytes and mast cells. These cells release cytokines to activate immune system. This activation leads to release of NO which causes vasodilation
Cytokines can make endothelial lining of blood vessels more permeable so fluid leaks into interstitial fluids causing oedema and distributive shock
Coagulation system also activated causing fibrin deposition in circulation further compromising organ and tissue perfusion. Causes DIC
Blood lactate rises as a result of anaerobic respiration in the hypo-perfused tissues with an inadequate oxygen
When should a child be screened for sepsis?
PEWS >3 ALWAYS SCREEN UNLESS OBVIOUS CAUSE
If they have infection e.g pneumonia, UTI, could be sepsis
What children are at higher risk of sepsis?
- Neonates to 3 months old
- Immunocompromised e.g. diabetes, splenectomy, immunosuppressants, cancer
- Recent surgery in the last six weeks
- Breach of skin integrity (burns/cuts/skin infections)
- Presence of an indwelling catheter or line
What is the definition of SIRS?
Suspected infection plus Symptoms
What are some symptoms and signs of sepsis in children?
- Fever OR hypothermia
- Generally feeling unwell
- Lethargy/Altered conscious level
- Continuous inconsolable crying in babies
- Pale or mottled skin
- Rash
- Decreased urine output
- Poor feeding or oral intake
- Cool peripheries
- Increased respiratory rate
- Increased respiratory effort
- Bradycardia or tachycardia
- Floppy
- Signs of dehydration (e.g. dry mucous membranes, decreased skin turgor, delayed capillary refill time)
What are some red flags for sepsis?
- If a child is not rousable, or does not stay awake when roused
- Bradycardia or tachycardia for age
- Bradypnoea or tachypnoea for age
- Mottled skin
- Peripheral or central cyanosis
- Non-blanching rash
What differentials should be considered for sepsis in children?
- Kawasaki Disease (prolonged fever)
- Simple infection (see if fever responds to antipyretics)
- Anaphylaxis
- DKA
- Bronchiolitis
NICE uses a traffic light system to determine risk of serious illness in under 5’s. What are some of the parameters that are looked at?
Remember anyone <3months with a temperature over 38 is sepsis until proven otherwise
- Colour
- Activity
- Respiratory
- Circulation and hydration
- Other
If sepsis is recognised how is this managed?
(use chart)
- Oxygen if sats <94%
- Obtain IV access (cannulation)
- Blood tests: FBC, U&E, CRP, clotting screen, blood gas for lactate and glucose
- Blood cultures
- Urine dipstick and laboratory testing
- Antibiotics within 1 hour of presentation
- IV fluids: if the lactate is above 2 mmol/L or there is shock
- Consider PICU referral
- Consultant review within 14 hours
What investigations are done during the sepsis 6 pathway?
Laboratory tests
- FBC
- CRP
- Coagulation
- Blood culture
- U+Es
- Blood gas for lactate and glucose
- Urine dipstick and US
What investigations are done after the sepsis 6 pathway to try and find the source of infection?
Imaging or invasive tests (done after sepsis 6 to locate source of infection)
- CXR if suspect pneumonia is cause
- Lumbar puncture (if under 3 months) if suspect meningitis
- Abdominal US if suspect intrabdominal infection
- Meningococcal PCR
How is amber flag sepsis managed?
What antibiotics are used in sepsis for the following groups of patients:
- <1 month
- 1 -3 months
- >3 months
< 1month: Gentamicin, Amoxicillin, Cefotaxime
1-3 months: Amoxicillin and Ceftriaxone
>3 months: Ceftriaxone
How long should antibiotics be continued for in sepsis?
5 – 7 days if a bacterial infection is suspected or confirmed
Alter antibiotic choice and duration once a source of infection is found and an organism is isolated
Consider stopping where there is a low suspicion of bacterial infection, the patient is well and blood cultures and two CRP results are negative at 48 hours
What is the prognosis with sepsis in children?
Linked to speed of recognition and antibiotic administration
Bacterial meningitis: need to monitor for long-term developmental delay, and audiological testing. Limb ischaemia may lead to amputations
If a child presents with a fever (temp >38) what questions do you need to ask?
- Onset, duration, pattern of fever, and method of temp measurement
- Associated symptoms suggesting an underlying cause of fever.
- Perinatal complications such as maternal fever or premature delivery
- Any significant medical conditions, e.g immunosuppression
- Any recent antipyretic drug and/or antibiotic use
- The child’s immunization history, and any missed immunizations
- Recent foreign travel
- Recent contact with people with serious infectious diseases
- Parental/carer health beliefs about fever and previous family experience of serious febrile illness (may increase parent/carer anxiety)
What observations do you need to do for a feverish child?
- General appearance
- Temperature
- Heart rate
- Respiratory rate
- Capillary refill time (CRT)
- Fluid status
How should a child with a fever be managed based on their traffic light score?
Green:
Child can be managed at home with appropriate care advice, including when to seek further help
Amber:
Provide parents with a safety net or refer to a paediatric specialist for further assessment
Red:
Refer child urgently to a paediatric specialist
If sending a feverish child home, what advice should you give parents?
ALWAYS SAFETY NET
- Avoid aspirin
- Not to use routine antipyretic drugs to prevent recurrent febrile seizures
- Looking for signs of dehydration in the child
- Offering regular fluids and encouraging a higher fluid intake
- Dress child appropriately for environment by not underdressing or over-wrapping
- Avoiding use of tepid sponging to lower the child’s temperature
- Checking the child regularly, including during the night
- Keeping the child away from nursery or school until they are recovered
- Look for rash
What are some signs you can tell parents to look out for that may indicate dehydration in their child?
- Poor urine output
- Dry mouth
- Sunken anterior fontanelle (usually closed by 18 months)
- Absence of tears
- Sunken eyes
- Ill appearance
How may hypothermia present in infancy?
- cold to touch
- floppy
- unusually quiet and sleepy
- refuse to feed
What should you NOT do when a child is hypothermic and why?
Risk of cardiac arrest
How is hypothermia managed?
- Remove any wet clothing and cover in warm blankets
- Warmed IV fluids
What is the definition of a febrile convulsion and what age group do they mostly occur in?
‘A seizure associated with a febrile illness not caused by an infection of the central nervous system, without previous neonatal seizures or a previous unprovoked seizure and not meeting the criteria for other acute symptomatic seizure, which occurs in children aged 6 months to 5 years’
Tend to occur early in viral illness
What are the most common causes of a febrile convulsion?
- URTI
- LRTI
- UTI
- Otitis media
What are some risk factors for febrile convulsions?
- Family history
- Socio-economic class
- Seasonal (higher prevalence of viral disease in the winter months)
- Zinc and iron deficiency
What are the different types of febrile convulsion and the characteristics of each?
Commonly tonic-clonic seizures
- Simple
- Complex
- Febrile Status Epilepticus (>30 minutes)
When examining a child after a febrile seizure, we are looking for a source of infection. What are some areas we might check?
- External ear examination with auroscope
- Throat examination: for signs of URTI (inflamed tonsils etc.)
- Full respiratory examination: for signs of LRTI
- Check fontanelles: raised anterior fontanelles with no pulsation
- Brudzinski’s or Kernig’s sign
- Nuchal rigidity
- Mental status of the child
- Full neurological examination
- Cardiovascular examination
- Abdominal examination
- Urine dipstick and microscopy
- Any superficial infective skin lesions
What are some differentials for a febrile convulsion?
- CNS infection – such as meningitis, encephalitis
- Raised ICP
- Delirium
- Epilepsy
- Syncope
- Hypoglycaemia
How should febrile convulsions be managed?
- A to E
- Keep child well hydrated
- Give ibuprofen antipyretic
- If >5 minutes give benzodiazepines
- Admit to hospital if first seizure or complex
What is the prognosis with febrile convulsions?
- 3% of all children will have one, 30% of these will have a recurrence
- Low (2%) risk of epilepsy if simple (background is 1%)
- 4-12% risk of epilepsy if complex febrile seizure
What are some risk factors for recurrent febrile seizures?
- Age at onset under 18 months.
- Short duration of fever before seizure (<1 hour).
- Relatively lower grade of fever associated with seizure (<40C)
- Multiple seizures during the same febrile illness
- Day nursery attendance
- Family history of febrile seizure in a first degree relative
Children meeting all of these risk factors having up to 80% risk of recurrence.
What advice do you need to give parents about recurrent febrile seizures?
- Regular antipyretics do not prevent them
- Call 999 if goes over 5 minutes
- Learn how to use rectal diazepam or buccal midazolam
What are the 3 risk factors for a child developing epilepsy in the future?
- Family history of epilepsy
- Complex febrile seizures
- Neurodevelopment delay
If all 3 then 50% chance!
What age group in suspected sepsis do children need a LP?
In oncology paediatric patients, what antibiotics are used if they develop sepsis?
- Piperacillin-Tazobactam
- Teicoplanin
