ABCDEENT paeds

Question 1

Approach to a child with a fever

Answer 1

History
- systematic review of ABCDEENT
- SHx home circumstances, recent travel, contacts ill?

ABCDEENTT
Traffic light system
Focused examination based on ddx

Question 2

systematic review history child witha. fever

Answer 2

Systematic review in order of ABCDEENTT
Airway
Have they been talking normally? Any weird sounds when they breathe?

Breathing
Have they looked like they are struggling to breathe? Any wheeze?

Circulation
Have they been weeing regularly - regular wet nappies? Drinking? Pale in your opinion?

Disability
Have they been acting normally for them? Have they been smiling still? Crying? Unresponsive at any point? Difficult to wake up?
Headaches? Avoiding light or sound? Pain in any joints? Able to walk around normally?

Exposure
Have you noticed any rashes
ENT
Have they complained of a sore throat? Have they been eating? Have they complained of sore ears or been tugging at their ears?
Temperature for how many days?

Tummy
Have they been complaining of tummy pain? Drawing legs up to their chest? Have they been pooing? Consistency, blood etc…
Pain when they wee?

Question 3

Airway examiantion and differentials

Answer 3

secretions, foreign body, stridor, if unconscious test gag reflex by trying to insert an oropharyngeal airway, if there is a gag reflex the child is protecting their airway.

If not, call an anaesthetist
- Secretions or stridor
- Foreign body
- Unprotected airway

ddx:
- Croup
- Epiglottitis

Question 4

Breathing examination and ddx

Answer 4

Assess respiratory rate, look for recession/accessory muscle use, check oxygen saturation, auscultate the chest
Respiratory rate (can indicate respiratory distress, septicaemia or DKA)
Oxygen sats (<94 hypoxia)
Respiratory: normal breathing versus respiratory distress, tachypnoea or grunting

• Croup
• Bronchiolitis
• Pneumonia
• Whooping cough

Question 5

Red flag for colour

Answer 5

Pale/mottled/ashen/blue skin

Question 6

Red flags for activity

Answer 6

No response to social cues

Appears ill to a healthcare professional

Does not wake or if roused does not stay awake

Weak, high-pitched or continuous cry

Question 7

Red flags for respiratory

Answer 7

Grunting

Tachypnoea: respiratory rate >60 breaths/minute

Moderate or severe chest indrawing

Question 8

Red flags for circualtion

Answer 8

Reduced skin turgor

Question 9

Other red flags

Answer 9

Age <3 months, temperature >=38°C

Non-blanching rash

Bulging fontanelle

Neck stiffness

Status epilepticus

Focal neurological signs

Focal seizures

Question 10

Amber for colour

Answer 10

Pallor reported by parent/carer

Question 11

Amber for activity

Answer 11

Not responding normally to social cues

No smile

Wakes only with prolonged stimulation

Decreased activity

Question 12

Amber for resp

Answer 12

Nasal flaring

Tachypnoea: respiratory rate

> 50 breaths per minute, age 6 to 12 months;

> 40 breaths per minute, age more than 12 months

Oxygen saturation less than or equal to 95% in air

Crackles in the chest

Question 13

Amber for circualtion

Answer 13

More than 160 beats per minute, age less than 12 months

More than 150 beats per minute, age 12 to 24 months

More than 140 beats per minute, age 2 to 5 years

Capillary refill time more than or equal to 3 seconds

Dry mucous membranes

Poor feeding in infants

Reduced urine output

Question 14

Amber for other

Answer 14

Age 3 to 6 months, temperature more than or equal to 39°C

Fever for more than or equal to 5 days

Rigors

Swelling of a limb or joint

Non-weight bearing limb or not using an extremity

Question 15

Cirucaltion examination

Answer 15

Assess colour skin, heart rate, capillary refill time (on sternum and fingers/toes), blood pressure, warm or cold hands/feet?
ASK ABOUT URINE
Colour: normal colour versus cyanosis, mottled pale or ashen
Circulation and hydration: normal skin and moist membranes versus tachycardia, dry membranes or poor skin turgor

Question 16

Disability examination

Answer 16

Assess pupil response to light, limb tone and movement, AVPU score/GCS
Activity: active, happy and responsive versus abnormal responses, drowsy or inconsolable cry

neuro - add kernigs
limbs - add weight bearing and examiantion of a joint if red hot swollen etc

Meningitis
Encephalitis
Septic arthritis
Osteomyelitis

Question 17

Exposure examination

Answer 17

skin for rashes
temerpature

Other: other concerning signs, such as fever > 5 days, non blanching rash, seizures or high temperatures < 6 months

Meningitis
Kawasaki disease

Question 18

ENT examination and ddx

Answer 18

Ears, Nose and Throat

• mucosal lesions

Tonsillitis
Kawasaki disease
Otitis media
Otitis externa

Question 19

Tummy examiantion

Answer 19

Is this soft? Distended? Tender? check kidneys!!!! What are the bowel sounds like? Any masses? Any hernias?
In boys, never forget to examine the testis (testicular torsion = surgical emergency)
Urinalysis

UTI
Pyelonephritis
Gastroenteritis
appendicitis

Question 20

D E F G – Don’t Ever Forget Glucose!

Answer 20

DKA
hypoglycaemia

Question 21

How does red/amber/green help you decide referral from primary care

Answer 21

If green:
Child can be managed at home with appropriate care advice, including when to seek further help

If amber:
provide parents with a safety net or refer to a paediatric specialist for further assessment
a safety net includes verbal or written information on warning symptoms and how further healthcare can be accessed, a follow-up appointment, liaison with other healthcare professionals, e.g. out-of-hours providers, for further follow-up

If red:
refer child urgently to a paediatric specialist

Question 22

Investigation and management of a child under 3 months with a fever

Answer 22

• Do bloods (FBC, CRP, blood culture)
• Do urinalysis
• CXR if resp signs present
• Stool culture if diarrhoea present
• Lumbar puncture and IV abx if:
  infants younger than 1 month
  all infants aged 1 to 3 months who appear unwell
  infants aged 1 to 3 months with a white blood cell count (WBC) less than 5 times 109 per litre or greater than 15 times 109 per litre

abx choice:
a third-generation cephalosporin (for example cefotaxime or ceftriaxone) should be given plus an antibiotic active against listeria (for example, ampicillin or amoxicillin)

Question 23

Invetsigation and management of a child over 3 months with a fever

Answer 23

red features:
- do FBC, blood culture, CRP, urinalysis
- consider LP, CXR, U&Es and blood gas

amber:
- same as above unless experiences paeds says not to
- lumbar puncture should be considered for children younger than 1 year
- chest X-ray in a child with a fever greater than 39°C and WBC greater than 20 times 109 per litre

green:
- urinalysis
- assess for signs of pneumonia

Question 24

Seriously unwell child with a fever, what are the different things you may give during ABCDE assessment

Answer 24

A - call anaethetist, if unrousable try oropharyngeal airway to test gag reflex

B - O2 if signs of shock or (SpO2) of less than 92% when breathing air or clinically indicated

C- fluid resuscitation fluid bolus of 10 ml/kg of 0.9% sodium chloride
IV abx if shocked

D- IV abx if unrousable or showing signs of meningococcal disease
IV aciclovir if signs of HSV encephalitis

E - IV abx if showing signs of meningococcal disease

Question 25

IV abx choice children

Answer 25

When parenteral antibiotics are indicated, a third-generation cephalosporin (for example, cefotaxime or ceftriaxone) should be given, until culture results are available. For children younger than 3 months, an antibiotic active against listeria (for example, ampicillin or amoxicillin) should also be given.

Question 26

when should you use paracetamol/ibruprofen in a child with a fever

Answer 26

Consider using either paracetamol or ibuprofen in children with fever who appear distressed.

continue only as long as the child appears distressed

consider changing to the other agent if the child’s distress is not alleviated

do not give both agents simultaneously

only consider alternating these agents if the distress persists or recurs before the next dose is due.

Question 27

advice for parents looking after a feverish child at home

Answer 27

Advise parents or carers looking after a feverish child at home:

to offer the child regular fluids (where a baby or child is breastfed the most appropriate fluid is breast milk)

how to detect signs of dehydration by looking for the following features:

sunken fontanelle

dry mouth

sunken eyes

absence of tears

poor overall appearance

to encourage their child to drink more fluids and consider seeking further advice if they detect signs of dehydration

how to identify a non-blanching rash

to check their child during the night

to keep their child away from nursery or school while the child’s fever persists but to notify the school or nursery of the illness.

Question 28

when should you re-assess a child with red/amber flags

Answer 28

after 1-2 hours

Question 29

measurement of body temperature at different ages

Answer 29

In infants under the age of 4 weeks, measure body temperature with an electronic thermometer in the axilla

4w-5 years can use a normal infra-red tympanic thermometer OR the electronic thermometer in the axilla

Question 30

when to suspect sepsis

Answer 30

if any red/amber flags present (NICE traffic light) then refer to guidelines…