30 - Emergency Paediatrics 2 Flashcards
What is the definition of a brief resolved unexplained event (BRUE)? (formerly known as ALTE)
An event occurring in an infant younger than 1 year when the caregiver reports a sudden, brief (<1 minute) and now resolved episode of ≥1 of:
- Change in colour
- Apnea
- Marked change in tone (hyper or hypotonia)
- Altered level of responsiveness
What is the epidemiology and risk factors of BRUE?
Epidemiology
- 1% of emergency presentations of infants less than a year old
- M>F
- Mean age 8 weeks
Risk Factors
- Infants < 2 months old
- Patients who were premature and have had multiple ALTEs
What is the pathophysiology of BRUE?
- GORD (50%)
- Idiopathic (50%)
What questions do you need to ask a parent when there is a BRUE episode?
- Timing
- Relation to feeding
- Previous episodes
- How does baby sleep?
- Any recent infection or family member unwell?
- PMHx (BIND)
- FHx of any cardiac or metabolism issues
- SHx and risks of this being NAI
What examination should you do for a child with BRUE?
General: Vital signs, BM, Growth (weight and head circumference), dysmorphic features, any bruises or marks suspicious of NAI
Respiratory including ENT: any signs of URTI or LRTI
CVS: femoral pulse for coarctation of aorta, any murmurs
Abdominal: Tenderness with a sausage shaped mass, groin for hernias
Neurological: pupil responses, limb tone, power, fundoscopy if suspect NAI
To guide investigations and management of BRUE, children are stratified as high risk or low risk. What are some low risk features?
- Age > 2months
- Gestational age >32 weeks
- No previous BRUE
- Event lasted < 1 minute
- No CPR required
- No concerning features in history or examination
What investigations are done for a high risk and low risk patient?
Low Risk
- ECG – exclude channelopathies, WPW or cardiomyopathy. Calculate QTc
- Consider pernasal swab for pertussis
High Risk
- ECG and pernasal swab for pertussis
- CXR
- Blood gas - may have metabolic acidosis if inborn error of metabolism
- FBC, Film, U+Es, CRP, bone profile, glucose
- Blood culture, Urine culture, LP if suspect sepsis/meningitis
What investigations need to be done if you suspect an inborn error of metabolism?
Serum amino acids and ammonia samples (on ice)
How are BRUE patients managed?
Parental reassurance and period of observation of child
Low Risk
- Safety netting advice for what to do if future episodes occur
- Formal Basic Life Support (BLS) training should be offered
- Follow up in primary care
- Observe feed if infant
High Risk
- Refer to paeds for admission and investigations
- Overnight oxygen saturation monitoring
- If stable discharge home with same advice as above
Transient hypoglycaemia (<2.6mmol/L) in the first 24 hours after birth is common and normal as babies can utilise lactate and ketones.
What are some causes of prolonged neonatal hypoglycaemia?
- Preterm < 37 weeks
- Maternal diabetes mellitus
- IUGR
- Hypothermia
- Neonatal sepsis
- Inborn errors of metabolism
- Beckwith-Wiedemann syndrome
What are some signs of hypoglycaemia in neonates and how is it managed?
- Asymptomatic
- Irritable
- Tachypnoea
- Pallor
- Poor feeding
- Weak cry
- Drowsy
- Hypotonia
- Seizures
- Apnea
- Hypothermia
Hypoglycaemia is define as <2.6mmol/L in babies aged <6 months and <3mmol/L if aged >6 months. What investigations need to be done when a child has hypoglycaemia?
Need to find a cause and bloods have to be taken at time of hypoglycaemia
After a hypo screen is taken, how is hypoglycaemia corrected in this emergency?
IMPORTANT CARD, LOOK AT IMAGE
Monitor BM hourly until stable, always take BM 10-15 minutes after intervention
If child is conscious and not vomiting
- PO glucose dextrogel 1⁄2 tube (5g) for infants <6 months and 1 tube if >6 months
- In an older child give oral glucose 10–20 g
- Followed by snack of starchy carbohydrates or a milk feed in infants
Altered consciousness
- 2 ml/kg 10% glucose/0.9% NaCl as IV bolus followed by infusion containing 10% glucose
- If no IV access stat glucagon IM: 0.5mg for patients < 8 yrs age or <25 kg, 1 mg for patients > 8 yrs age or >25 kg. Followed by IV or IO infusion of glucose
How do you calculate glucose infusion rate and what does this tell you?
Most children will be normoglycemia on 5-8 mg/kg/min
If <12 think hyperinsulinaemia so refer urgently to endocrinology
How does malnutrition present in children?
- not growing or putting on weight at the expected rate (faltering growth)
- changes in behaviour, such as being unusually irritable, slow or anxious
- low energy levels and tiring more easily than other children
What are causes of malnutrition in children?
- Poverty
- Eating disorder
- CHD
- Cerebral palsy
- Diarrhoea
- Coeliac’s
- Cystic fibrosis
How is malnutrition in children managed?
- Eating foods high in energy and nutrients
- Support for families
- Treatment for any underlying medical conditions
- Vitamin and mineral supplements
- Regular weight and height monitoring
Severely malnourished children need to be fed and rehydrated in hospital and gradually being reintroducing food
What is the treatment for the following overdoses?
What is the treatment for the following toxins/overdoses?
What is the treatment for the following toxins/overdoses?
Give oxygen for cyanide poisoning to all children
What are the most common causes of overdose in children?
- Paracetamol
- Ibuprofen
- Aspirin
- Iron preparations
- Cough medicine
- COCP
- Asthma medication
What databases should be use to guide management of overdose?
- TOXBASE
- National Poisons Information Service
Always try to establish what poison, how much, over what period of time
What are some common signs of OD in children that need managing?
OD is treated supportively majority of the time
- Respiratory depression
- Hypotension
- Arrhythmias
- Hypo/hyperthermia
- Convulsions (give benzos)
When should you not use activated charcoal for OD?
- >1 hour since ingestion
- Petroleum distillates
- Alcohols
- Cyanides
- Iron and lithium salts