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Paediatrics > 4. Emergencies in Paeds > Flashcards

4. Emergencies in Paeds Flashcards

1
Q

What are the signs of Respiratory Distress in the child?

A 
Grunting
Tachypnoea
Tachycardia
Cough
Wheeze
Stridor
Apnoea
Cyanosis
Tracheal tug
Nasal flaring
Recession
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2
Q

What are the potential causes of respiratory distress?

A

Infection

  • Viral (Bronchiolitis)
  • Bacterial infection

Exacerbation of asthma/recurrent wheeze

Cardiac failure

Foreign body

Drugs ( accidental, poisoning, iatrogenic)

Neuromuscular causes: Guillain Barre,

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3
Q

Describe the assessment of a child in respiratory distress?

A 
AIRWAY
Is the airway patent? Can they talk? Cry?
Do they need suctioning?
Positioning 
Guedel airway

BREATHING
What is the oxygen saturations?
Give oxygen

CIRCULATION
Heart rate
Pulse ( thready, good volume)
Capillary refill
Blood pressure
Cold peripheries
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4
Q

How is the severity of respiratory attacks categorised?

A

Moderate

Severe

Life –Threatening

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5
Q

What are the signs of a moderate respiratory (asthma) attack?

A 
Able to talk in Sentences
Sp02: ≥92%
PEF: ≥50% of best/predicated
HR: ≤140 (2-5yrs) ≤125 (>5 years)
RR: ≤40/min (2-5yr), ≤30/min (>5 years)

*Note: PEF often not done in the ED, so do it!

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6
Q

What are the signs of a severe respiratory (asthma) attack?

A

Cannot complete sentences in one breath or too breathless to talk or feed.

SP02: 140 (2-5ye), >125 (>5yr)
RR: >40/min (2-5yr), >30 (>5yr)

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7
Q

What are the signs of a moderate respiratory (asthma) attack?

A

Any 1 of the Following in a Child with Severe Asthma

CLINICAL SIGNS
Silent Chest
Cyanosis
Poor Respiratory Effort
Hypotension
Exhaustion
Confusion

MEASUREMENTS
Sp02 <33% of best/pred

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8
Q

What is the Treatment for Acute Asthma?

A

MILD
Salbutamol (Beta-Agonist) via MDI (inhaler)
Oral prednisolone

MODERATE:
Salbutamol (Ventolin) via MDI
Ipatropium bromide (Atrovent - An Anti-Cholinergic) via MDI
Oral prednisolone

SEVERE:
Oxygen
“Back to back nebs” (every 20 minutes)
Nebulised salbutamol
Nebulised ipatropium bromide
Oral or maybe IV steroids
LIFE THREATENING
As in severe, but continuous nebulisers
IV hydrocortisone
Magnesium sulphate
Aminophylline
Call PICU
If a child fails to respond in severe or life threatening group to nebuliser other treatment option include
Magnesium sulphate IV (bronchodilator)
Aminophylline IV (bronchodilator)
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9
Q

What does MDI stand for?

A

Metered Dose Inhaler

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10
Q

What are the admission criteria for asthmatic exacerbation?

A

If asevere episode

Fails to respond to moderate treatment

Needing oxygen ( O2 saturation <92%)

Previous ICU admission for asthma

Increased work of breathing ( tracheal tug, recession, increased RR)

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11
Q

What is Stridor?

A

Latin for creaking or grating noise” is a high-pitched breath sound resulting from turbulent air flow in the larynx or lower in the bronchial tree.

Due to upper airway obstruction (not necessarily FB)

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12
Q

What are the causes of stridor in a child?

A 
Croup (Most Common)
Bacterial Trachetitis
Epiglottitis
Foreign Body obstruction
Angio-oedema (anaphlaxis
Laryngomalacia
Thermal chemical injury
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13
Q

In whom is croup most common? What are the Symptoms?

A

Croup: 6 months- 5years

Coryzal symptoms
Barking cough
Able to drink
Genereally temp < 38.5
Harsh stridor (Stridor typically acute onset, at night time.)
No drooling 
Hoarse voice
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14
Q

What is contraindicated in stridor?

A

Do not move the child from a comfortable position.
Do not insert a tongue depressor
Do no take blood
Do not X-ray

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15
Q

How is the severity of croup assessed?

A

MILD CROUP
Barking cough, no stridor
Give oral dexamethasome

MODERATE CROUP
Stridor and chest wall recessions
Give oral dexamethasome
May need adrenaline

SEVERE CROUP
Agitation/lethargic, increased WOB, Reduced Air entry
Nebulised Adrenaline
Oxygen
PICU

Reduced O2 = Very Late Sign

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16
Q

What is the most common cause of life-threatening infection in children?

A

Meningococcal Infection

Fatel w/o Tx

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17
Q

What is the aetiology of Meningococcal Disease?

A

N. Meningitides serogroup B most common
Serougroup C is rare since the introduction of vaccination (since October 2000)

Once bactermia occurs, bacterial autolysis leads to endotoxin release and sytemaic illness with DIC, capillary leak and shock

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18
Q

What is the clinical course of Meningitidis?

A

Early stages signs and symptoms are non-specific

Presents with severe sepsis and/or meningitis

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19
Q

What are the clinical features of Meningitidis

A 
NON-SPECIFIC
Fever
Malaise
Rash
Cough
“flu-like” symptoms
Headache and photophbia
Leg pains
Cold hands and feet

RASH
Maculopapular
Petechial
Purpuric (non-blanching)

SHOCK
Signs of shock (Cap ref, HR, BP)

RAISED ICP + MENINGITIS
Neck stiffness
Photophobia)

GCS low

20
Q

What is the assumed Dx for a child with fever + Petechial Rash?

A

Menigococcal septicemia until proven otherwise

21
Q

What is the Tx for Meningococcal Septicemia?

A
  1. RESUSCITATION
    ABC: Airway, breathing and circulation
    20mL/kg of normal saline (may need to repeat )
  2. ANTIBIOTICS
    IV third generation cephlasporin
    If no IV access or in GP surgery give IM benzylpenicillen
3. Bloods: 
FBC (raised WCC, low platelets) 
Group and cross match (blood products
Coagulation (to determine need for blood products)
CRP (sign of infection)
Blood culture
PCr for meningococcal disease
  1. INOTROPIC SUPPORT
    ( Low BP due to vasodialtion)
  2. TREATMENT OF COAGULOPATHY
22
Q

Which procedure is C/I in meningococcal septicemia?

A

LP contra-indicationed if signs of raised ICP, cardio-resp instability, sepsis in areas where the need will pass, evidence of coagulopathy

23
Q

What are the complications?

A
  1. Mortality (3-10%)
  2. Loss of digits and limbs due to peripheral vascular disease
  3. Renal injury
24
Q

What is the Ddx in Purpuric Rash?

A 
Meningococcal disease
Henoch-Schonlein purpurs (vasculitis) 
Idiopathic thrombocytopenia (no fever, viral 2wks, no platelets)
Non-accidental Injury
Disseminated intravasular coagulation
Viral illness
ALL
Coughing & vomiting (should be only in upper 1/3 of chest wall)
25
Q

What is Status Epilpticus?

A

Generalised tonic- clonic seizure > 30 minutes

Recurrent seizures without recovery of consiousness

26
Q

What are the common causes of Status Epilepticus?

A

Common causes: Fever, known seizures, CNS infection, poisining, trauma,

27
Q

What is the Tx for Status Epilepticus?

A

Treatment

Resuscitation
ABC : airway, breathing and circulation
Identify any reversible causes
Is the blood sugar low? Level: <2.6 mmol/L
Dextrose 10% 2mL/kg and re-check sugar in 10 minutes.

Drugs
First Line: Benzodiazepienes
IV lorazepam 0.1mg/kg
PR diazepam  (dose dependent on age)
Buccal midazolam (dose dependent on age)
Can only give twice

Second Line: Fosphenyotin/ Phenytoin

Third Line: Depends (Levetiracetam, Lacosamide, Sodium Valproate)

Fourth Line: Phenobarbitone

28
Q

What is the management after a seizure has stopped?

A

Identify the underlying causes
CNS infection
Febrile convulsion (Do they have a temperature?)
Known seizure disorder
Head injury/trauma
Presentation of brain tumour
Metabolic abnormalities (Hyponatremia, hypernatremia)

29
Q

What is a common s/e of benzodiazepines?

A

Child can become very sleepy.

30
Q

What is DKA?

A

Diabetic Ketone Acidosis.

DKA results from a shortage of insulin; in response the body switches to burning fatty acids and producing acidic ketone bodies that cause most of the symptoms and complications.

31
Q

What is expected in the Hx of a patient with DKA?

A 
Polyuria
Polydipsia
Polyphagia 
Weight loss
Vomiting
Abdominal Pain
Drowsiness
32
Q

When does Cerebral Oedema occur in DKA?

A

A rare but serious complication of DKA only found in children.

33
Q

What might be found on examination of a patient with DKA?

A 
Low Glasgow Coma Scale
Kussmauls respirations
Ketotic breath
Signs of shock
Signs of Infection
Ileus
34
Q

What are lab signs of DKA?

A

Blood glucose : >11mmol/L

pH : 3 mmol/L

35
Q

What is the initial Tx for DKA?

A

Begin with resuscitation

ABC : airway, breathing and circulation

If Signs of Shock = Bolus –DKA we give 10ml/kg bolus of 0.9% Saline over ten minutes. = Helps reduce sugar.

Treat shock

Bloods

  • Laboratory glucose
  • Blood Gas
  • Urea and Electrolytes
  • If a new patient: HbA1c, thyroid function, anti-TPO ab, anti-GAD, anti-Insulin and anti-IA2 ab
36
Q

Following initial Tx what is the objective of treatment?

A

Correct Dehydration

Begin Insulin Therapy

Prevent Complications

37
Q

What is the Tx for Dehydration in DKA?

A
  1. FLUID REGIME

2. Electrolytes

38
Q

What is the Fluid Regime in DKA?

A

Use 0.9% normal saline initially (20mmol kcl in 500ml)

+/- Dextrose (If blood glucose 5mmol/hr)

Restore deficits over 48 hours

Fluid requirements = Maintenance + Deficit

Need to decide if the child is 3%, 5% or 8% dehydrated

Subtract volume of bolus from maintenance fluids

39
Q

When is Dextrose Added to resus fluids in DKA?

A

5% dextrose is added if
Blood glucose if dropping > 5mmol/hour
Blood glucose <14.1mmol

40
Q

What is the Tx for electrolyte imbalance?

A
  1. POTASSIUM
    - Total body potassium is depleted.
    - Need to add potassium to IV fluids from the start of maintenance fluids
    - Potassium levels will fall once insulin is commenced (insulin decreases blood potassium by redist into cells, but much already lost in urine)
    - Check Electrolytes 2 hourly initially then 2-4 hourly
  2. SODIUM
    - A rapid fall in plasma osmolarity and/or fall in sodium maybe assoicated with cerebral oedema
    - Hyperglycemia causes falsely low plasma sodium level. Should rise slowly.
    - There is a formula to calculate sodium in the setting of DKA ( do not need to know)
    - Ideally sodium should not rise faster than 0.5mmol/hr
41
Q

Describe the use of Insulin Therapy in the setting of DKA?

A

Do not start until shock (if present) has been reversed

Hydrate First

Wait an hour after commencing fluids before starting IV insulin

Give 0.1internationl unit/kg/hour of insulin

Check Glucose hourly

Do not want it too fall to quickly
Aim: fall 4-5mmo/hr

Add dextrose to normal saline 0.9% fall >5mmol/hour or when sugar <15mmol then add dextrose to IV fluids

42
Q

Describe the post Tx monitoring of a DKA patient?

A

Hourly vitals and neuro observations

Hourly blood glucose and blood ketone measurements

Stop or reduce IV insulin as indicated

43
Q

When should iV insulin be stopped or reduced? What must be done following?

A

When:

PH> 7.3
Blood glucose < 14mmol/L
Child eating and drinking

Need to start Sub-cutaneous insulin if stopping IV insulin

44
Q

What are the warning signs of cerebral oedema?

A

Headache, behavioural change, restlessness
Body posturing, cranial nerve palsy, seizures
Slowing of heart rate, haemodynamic instability
Respiratory arrest

45
Q

What is the Tx for cerebral oedema?

A

IV Mannitol

Urgent CT Brain

Paediatrics (7 decks)

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