3. Paediatric clinical reasoning Flashcards
A 15 year old child presents to A&E with paracetamol overdose. Mum is with them. Talk through your management of this child…
- Immediately go and assess with a History and an A-E assessment. I would alert my senior that I am going to assess a child with an overdose presentation just to make them aware, but happy to go and do an initial assessment independently and immediately go and get help if I felt out of my depth.
- I would ask the child if they wanted mum to stay in the room for history (this could make them at ease, or actually they may prefer mum to leave to disclose more info)
- Clear history of overdose (accidental vs intentional, staggered vs taken all at once), if intentional was it planned or spontaneous, were there any triggers or drivers e.g. family issues, stress at school, body image issues etc.
- Throughout the history I would be assessing if I thought the child had capacity or whether they were too young to make decisions for themself and whether parental involvement was still legally obliged as they are under 18yrs.
- Thorough psych component of the history given this is an overdose should also be taken, does the child have chages to their body language, and ongoing delusions (ASEPTIC etc…)
- Then move onto A-E examination (airway, are they talking to me?) (breathing, are the lung fields clear or could they have vomited and aspirated if the overdose was also taken with a sedative like alcohol?) (C - heart rate and BP) (D - pupils, temperature, glucose) (E - any rashes, injection marks, or self harm marks, or any concerning bruises could this be NAI?)
- Investigations: bloods including paracetamol level (most guidelines say 4hrs post ingestion but I would check this) and explain why this helps determine treatment to mum and parent, weight, LFT’s, U&E’s and FBC)
- Before sending off bloods would also get up the local paracetamol overdose guidelines or toxbase, as sometimes if a staggered overdose you treat anyway with N-acetyl cysteine regardless of the paracetamol level.
- Most likely (after checking guideline) NAC will be the treatment. NAC works by acting as synthetic glutathione and replacing the body’s glutathione stores which are depleted by the detoxification reactions involved in metabolising too much paracetamol.
- While awaiting the NAC level I would go and handover to my senior, using SBAR…
- They may then do a tier 2 review or help me with my clinical reasoning to decide if my plan was appropriate, if I should get a formal psych review or if I needed any child protection or child social work involvement.
A child presents with vomiting and dehydration. They are T1DM. Triage nurse is worried this is DKA. How would you manage the patient?
Immediately alert senior as I go in to start A-E assessment.
- Talk through A-E and what I might find (are they breathing, high RR (Kussmaul breathing), can I smell pear drops, any aspiration if recently vomiting, are they dehydrated or shut down, ask about vomiting and feeding and wet nappies, D - check a BM, urine ketones, or blood ketones, neurological status ?cerebral oedema if headache, irritability or reducing conscious level)
- E - any rashes, what is their work of breathing)
Quick Hx from child and parents as to triggers (missed insulin, concurrent illness etc).
Management - refer to guidelines! But principles are:
- IV fluids
- IV insulin
- further fluids with glucose and potassium replacement as insulin drives potassium intracellularly
- speak to PICU
A child presents with worsening breathlessness, and a history of asthma. Parents are concerned. Using normal salbutaml inhaler with no benefit. Talk through your assessment of this child and some differentials and their management.
Immediately alert senior if they were not already aware from triage.
Keep parents with child if they were young to reassure them and minimise distress for child and parent by separating.
A - are they speaking so I know they are not choking? Are they speaking in sentences?
B - What is their RR and sats. Normal ranges as per the PILS or paeds ALS handbook vary for different ages, but I would compare these. What is their WOB? (intercostal muscles, cyanosis, head bodding, grunting) If concerned immediately start on 15L trauma mask with oxygen and then titrate down as appropriate, or if child won’t tolerate this and mask would cause too much distress then hold it in front of their face and waft. Also consider blood gas and CXR at this stage.
- Would pull the emergency buzzer at this point to get nursing staff and more clinicians in the room to help at this point as I continue my assessment.
- C again check HR and BP against chart. How hydrated do they look? Ask mum about wet nappies and feeding. Any vomiting? Colour and CRT.
- Check a BM if this will not distress the child, pupils, check how alert and responsive they are (are they crying strongly and eyes open and able to answer Q’s, or are they drowsy and quiet?)
- look for rashes
After examination quick Hx from parents to help establish cause for SOB:
- is there Hx of asthma
- are there unwell contacts at home with viral things
- any new pets, new washing detergents that could have caused asthma to flare
- any preceding coryzal symptoms?
- any fever?
- ask parents red flags -> have they ever required IV therapy for wheeze before or been in PICU?
Differentials:
- Asthma exacerbation (managed with O2, salbutamol inhaler, oral prednisolone, nebulised salbutamol/ipratropium/magnesium/IV magnesium)
-Bronchiolitis (caused by RSV, preceding coryzal symptoms, then increased WOB and dehydration, common <2yrs lower resp tract infection) (managed with supportive care and fluid management)
- Foreign body aspiration
- Croup (like bronchiolitis but more stridor than wheeze) (manage with hands off approach, give oral dex if mild or IV dex if severe, possibly nebulised adrenaline)
A child is brought in by parents after having a seizure at home. Have been unwell with fever and sore throat for last 2 days. Talk through your assessment and management of this child:
After 5 mins - benzodiazepine
After another 5 mins - repeat benzo
After another 5 mins - levetiracetam
Febrile seizure info:
- red flags are having more than one seizure in the same febrile illness or focal seizures or signs of meningitis or no signs of a source of infection
- you can give antipyretics for symptoms only but not to prevent seizure
- 2% chance of developing epilepsy compared to 1% chance in the general population
What is the definition of a child in need?
They are a child in need if they are unlikely to achieve or maintain, or to have the opportunity of achieving or
maintaining, a reasonable standard of health or development without the provision
for them of services by a local authority
List differentials for a non blanching rash in children
HSP = type of IgA vasculitis with immune deposits under skin and in joints, leg and bum rash
HUS = thrombocytopenia + haemolytic anaemia + AKI
ITP
Meningococcal sepsis!
Viral illness
Trauma
in GP ALWAYS REFER!
