4. Emergencies in Paeds Flashcards
What are the signs of Respiratory Distress in the child?
Grunting Tachypnoea Tachycardia Cough Wheeze Stridor Apnoea Cyanosis Tracheal tug Nasal flaring Recession
What are the potential causes of respiratory distress?
Infection
- Viral (Bronchiolitis)
- Bacterial infection
Exacerbation of asthma/recurrent wheeze
Cardiac failure
Foreign body
Drugs ( accidental, poisoning, iatrogenic)
Neuromuscular causes: Guillain Barre,
Describe the assessment of a child in respiratory distress?
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
How is the severity of respiratory attacks categorised?
Moderate
Severe
Life –Threatening
What are the signs of a moderate respiratory (asthma) attack?
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!
What are the signs of a severe respiratory (asthma) attack?
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)
What are the signs of a moderate respiratory (asthma) attack?
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
What is the Treatment for Acute Asthma?
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)
What does MDI stand for?
Metered Dose Inhaler
What are the admission criteria for asthmatic exacerbation?
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)
What is Stridor?
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)
What are the causes of stridor in a child?
Croup (Most Common) Bacterial Trachetitis Epiglottitis Foreign Body obstruction Angio-oedema (anaphlaxis Laryngomalacia Thermal chemical injury
In whom is croup most common? What are the Symptoms?
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
What is contraindicated in stridor?
Do not move the child from a comfortable position.
Do not insert a tongue depressor
Do no take blood
Do not X-ray
How is the severity of croup assessed?
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
What is the most common cause of life-threatening infection in children?
Meningococcal Infection
Fatel w/o Tx
What is the aetiology of Meningococcal Disease?
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
What is the clinical course of Meningitidis?
Early stages signs and symptoms are non-specific
Presents with severe sepsis and/or meningitis
What are the clinical features of Meningitidis
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
What is the assumed Dx for a child with fever + Petechial Rash?
Menigococcal septicemia until proven otherwise
What is the Tx for Meningococcal Septicemia?
- RESUSCITATION
ABC: Airway, breathing and circulation
20mL/kg of normal saline (may need to repeat ) - 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
- INOTROPIC SUPPORT
( Low BP due to vasodialtion) - TREATMENT OF COAGULOPATHY
Which procedure is C/I in meningococcal septicemia?
LP contra-indicationed if signs of raised ICP, cardio-resp instability, sepsis in areas where the need will pass, evidence of coagulopathy
What are the complications?
- Mortality (3-10%)
- Loss of digits and limbs due to peripheral vascular disease
- Renal injury
What is the Ddx in Purpuric Rash?
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)
What is Status Epilpticus?
Generalised tonic- clonic seizure > 30 minutes
Recurrent seizures without recovery of consiousness
What are the common causes of Status Epilepticus?
Common causes: Fever, known seizures, CNS infection, poisining, trauma,
What is the Tx for Status Epilepticus?
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
What is the management after a seizure has stopped?
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)
What is a common s/e of benzodiazepines?
Child can become very sleepy.
What is DKA?
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.
What is expected in the Hx of a patient with DKA?
Polyuria Polydipsia Polyphagia Weight loss Vomiting Abdominal Pain Drowsiness
When does Cerebral Oedema occur in DKA?
A rare but serious complication of DKA only found in children.
What might be found on examination of a patient with DKA?
Low Glasgow Coma Scale Kussmauls respirations Ketotic breath Signs of shock Signs of Infection Ileus
What are lab signs of DKA?
Blood glucose : >11mmol/L
pH : 3 mmol/L
What is the initial Tx for DKA?
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
Following initial Tx what is the objective of treatment?
Correct Dehydration
Begin Insulin Therapy
Prevent Complications
What is the Tx for Dehydration in DKA?
- FLUID REGIME
2. Electrolytes
What is the Fluid Regime in DKA?
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
When is Dextrose Added to resus fluids in DKA?
5% dextrose is added if
Blood glucose if dropping > 5mmol/hour
Blood glucose <14.1mmol
What is the Tx for electrolyte imbalance?
- 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 - 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
Describe the use of Insulin Therapy in the setting of DKA?
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
Describe the post Tx monitoring of a DKA patient?
Hourly vitals and neuro observations
Hourly blood glucose and blood ketone measurements
Stop or reduce IV insulin as indicated
When should iV insulin be stopped or reduced? What must be done following?
When:
PH> 7.3
Blood glucose < 14mmol/L
Child eating and drinking
Need to start Sub-cutaneous insulin if stopping IV insulin
What are the warning signs of cerebral oedema?
Headache, behavioural change, restlessness
Body posturing, cranial nerve palsy, seizures
Slowing of heart rate, haemodynamic instability
Respiratory arrest
What is the Tx for cerebral oedema?
IV Mannitol
Urgent CT Brain
