Acute presentations Flashcards
sepsis
- Sepsis is a life-threatening illness caused by the body’s response to an infection.
- Recognising sepsis is often very difficult in children as symptoms and signs can be similar to self- limiting or less severe conditions.
- Bacterial infections are by far the commonest cause of sepsis (can be viral or fungal).
- Sepsis is defined as suspected/proven infection with Systemic Inflammatory Response (SIRS).
presentation of sepsis
SIRS is the presence of at least 2 of the following:
One of which must be temperature or WCC
- Core temperature > 38.5oC or < 36oC.
- Tachycardia (in absence of external stimuli). Tachypnoea for age (or ventilation).
- White cell count elevated or depressed
screening for sepsis
managment of sepsis
anaphylaxis
- Severe, life-threatening allergic reaction that is acute in onset and can cause death.
differentials for anaphylaxis
- Skin: Acute urticaria.
- GUT: Food poisoning, gastroenteritis.
- Respiratory: URTI, irritant rhino-conjunctivitis, choking, viral wheeze. acute asthma exacerbation.
- CVS: vasovagal syncope, panic attack.
presentation of anaphylaxis
- Angioedema same pathophysiology as urticaria, however occurs in deeper layer of the skin with no itch receptors therefore not itchy like acute urticaria
management of suspected anaphylaxis
classic history for acute urticaria
- Woke this morning with rash:
- Raised erythematous plaques.
- Some have pale centre.
- Rash spreading; plaques coalescing.
- Rash intensely pruritic.
- Agitated, irritable and unhappy.
- No previous allergies; eats all foods.
- No recent new contact – food, drug.
acute urticaria background
- Also called hives, wheals or welts.
- Common condition affecting up to 20% of population.
- Typically intensely pruritic erythematous plaque.
- May be associated with angioedema (swelling).
- Commonly categorized by chronicity:
- Acute: <6 weeks; triggers allergy, URTI, idiopathic.
- Chronic: >6 weeks; spontaneous or physical triggers
presentation of acute urticaria
Presentation
- Intensely pruritic rash
- Agitated, irritable, unhappy
- Spreading rash
- Raised erythematous plaques
management of acute urticaria
- History and examination to make diagnosis.
- In new-onset acute urticaria where assessment does NOT suggest underlying cause, NO investigations; may consider FBC and CRP if worried about vasculitis.
- High-dose non-sedating antihistamines.
- ± Oral glucocorticosteroids.
paracetamol overdose protocol overview 1/2
history for paracetamol overdose
o Dose
o Timing
o Associated ingestions
paracetamol overdose protocol overview 2/2
management of paractermaol overdose
charcoal only if very recently ingested
defintive treatment: N-acetylcysteine infusion
differential diagnosis
* Pre-septal cellulitis.
* Orbital or Post-septal cellulitis. * Allergicconjunctivitis.
* Bacterial conjunctivitis.
* Trauma.
* Sub-periostal/orbital abscess. * Cavernous sinus thrombosis.
history and examiantion for red swollen eye
- Acuity of onset?
- Recent URTI?
- Local insect bite, impetigo or conjunctivitis?
- Trauma?
- Eye pain, visual acuity, headache?
- Erythema/swelling of lid/surrounding tissue.
- Conjunctiva – white or red/swollen.
- Impaired eye movement (ophthalmoplegia).
- Painful eye movements.
- Impaired visual acuity.
presentation of pre-septal and orbital cellulitis
Pre-septal cellulitis
- Ocular itching is a prominent symptom.
- Bilateral conjunctival redness and swelling.
- Symptoms on exposure.
**Conjunctivitis ** - Redness and discharge from one eye.
- Affected eye ‘stuck shut’ in the morning.
- Colour/consistency depends on cause.
- Caused by bacteria (Staph. Aureus, H. Strep,
H. Influenzae) chlamydia, viruses.
pre-septal vs orbital cellulitis
Pre-septal cellulitis: inflammatory disease of the orbit limited to the tissues anterior to the orbital septum.
Orbital cellulitis: inflammatory disease of the superficial and deep structures of the orbit.
aetiology of pre-septal cellulitis
- 85%+ cases are pre-septal cellulitis.
- Commonly follows URTI and sinusitis (ethmoid commonest).
- Respiratory pathogens (Streptococcus, Haemophilus) commonest.
- Other sources: spread from skin, lachrymal ducts, middle ear etc.
examiantion for pre-septal vs orbital (more serious) cellulitis
management of pre-orbital sepsis
- Admit.
- IV access.
- FBC/CRP, cultures.
- Nose swab.
- IV Ceftriaxone.
- ± IV Metronidazole
- (if sinuses involved)
- Prompt ENT and
Ophthalmology
review. - 4h obs.
- Consider CT scan.
pneumonia differentials
- Bronchiolitis (Viral CAP). * Pertussis.
- Heart failure.
- Sepsis.
- Metabolic acidosis.
- Non-infectious mimics.
pneumonia differentials
- Bronchiolitis (Viral CAP). * Pertussis.
- Heart failure.
- Sepsis.
- Metabolic acidosis.
- Non-infectious mimics.
signs of pneumonia
fine crackles
bronchial breathing
reduced air entry
wheeze
Fine crackles:
- Short, explosive, non-musical sounds.
- Heard during mid-to-late inspiration.
- Sounds like Velcro being gently separated.
- Made by sudden opening of small airways.
- NOT affected by coughing.
- Also heard in: pulmonary fibrosis.
heart failure.
Bronchial breathing:
Bronchial breathing:
* Heard in both phases of respiration.
* Sounds like tracheal sounds.
* Indicates airway surrounded by consolidated
lung tissue – transmitting sound to surface.
Reduced air entry.
.
- Consolidation with embedded airways blocked by inflammation or secretions
Wheeze:
- High-pitched usually expiratory sound.
- Suggests airway narrowing.
- Can be present in pneumonia.
investigations severity assessment for pneumonia
bacterial vs viral caap presentation
management of CAP
ALL suspected bacterial CAP need antibiotics
Oral for moderate CAP unless can’t tolerate.
IV for severe/complicate ± moderate.
Duration depends on severity and response.
- Non-severe: Amoxicillin ± Clarithromycin.
- Severe: Co-amoxiclav ± Clarithromycin.
-or- Cefuroxime ± Metronidazole
define Brief Resolved Unexplained Event BRUE - formerly acute life-threatening event
A sudden, brief, now resolved episode in an infant with:
- Cyanosis or pallor,
- Absent, decreased or irregular breathing,
- Marked changes in tone (hypo- or hyper-tonia),
- Altered level of consciousness
Applies only when no other explanation after assessment
1. Brief = <1 minute.
2. Now resolved = infant asymptomatic on presentation.
3. 3. With = 1 or more criteria.
BRUE risk screening for discharge
- Age >60 days
- If premature: born at gestational age >32 weeks and
current postconceptional age >45 wks. - Only 1 BRUE (NO prior BRUE i.e., first event).
- Duration of BRUE <1 minute.
- NO CPR required by trained medical care provider.
low risk BRUE management
- Educate caregiver; offer CPR training.
- ± ECG and O/N monitoring.
high risk BRUE management
- Admit for continuous oximetry observation.
- ECG.
- FBC, bicarbonate, glucose, metabolic screen.
- Blood and urine culture.
- Respiratory virus testing; Pertussis testing.
- Observe/evaluate feeding.
- Prescribe anti-reflux medication.
- Home monitoring.
Asthamtic history
- Acuity of onset?
- Potential trigger - recent URTI? allergen exposure?
Background asthma history?
- Regular asthma medication.
- Frequency of preventer use.
- Frequency of/last course of oral steroids.
- Previous ED and GP attendances.
- Social impact – days off school.
Risk of severe asthma?
- Repeated ED attendance esp. In last year.
- Previous admissions, esp. in last year.
- Previous near fatal asthma (ICU admission).
- Pulse and respiratory rates; SpO2 in air.
- Work of breathing – use of accessory muscles.
- Breath sounds – unequal, silent chest?
- Amount of wheeze.
**Other causes/complications? **
- Pneumonia
- Pneumothorax.
assessment of asthma severity
management of acute asthma exacerbation
history for croup
- Acuity of onset?
- Any preceding symptoms: runny nose; fever?
- Other symptoms:
Toxicity (very high To). Choking episode/trigger. Drooling.
Voice changes/hoarseness. Cyanotic episodes. - Vaccinationstatus?
- Abnormal respiratory sounds/stridor.
- Respiratory status – RR; WOB.
what is croup
common (>95%) cause of laryngotracheal infections
- Typically occurs between 6mo and 6yr (peak 2yr).
aetiology of croup
Parainfluenza virus (commonest).
Influenza virus, RSV, Adenovirus. Measles.
presentation of croup
hoarse voice.
barking cough. stridor.
± fever.
differential for croup
stridor, stertor or wheeze
scoring croup
Westley croup severity score
management of croup accoridng to Westley severity
epiglottitis
Epiglottitis is inflammation and swelling of the epiglottis. It’s often caused by an infection, but can also sometimes happen as a result of a throat injury. The epiglottis is a flap of tissue that sits beneath the tongue at the back of the throat.
aetiology of epiglorttiis
Epiglottitis is inflammation and swelling of the epiglottis. It’s often caused by an infection, but can also sometimes happen as a result of a throat injury. The epiglottis is a flap of tissue that sits beneath the tongue at the back of the throat.
clinical presentation of epiglottitis
.
children with epiglottiis may sit in a certain position
management of epiglottitis
1) Secure the airway
2) Give oxygen if sats <92%
3) IV antibiotics (e.g. ceftriaxone)
4) Steroids (i.e. dexamethasone)
sickle cell
- Autosomal recessive inheritance.
- Commonly in black and Afro-Caribbean people
natural hisotry of sickle cell disease
Common factor in distribution is history of malaria or migration from a malaria area.
* Carrier offers protection against malaria.
sickle cell disease pathophysiology
- Mutation in the Beta-globin gene.
- Changes 6th amino-acid - glutamine to valine.
- HbS is insoluble when deoxygenated forming * polymers which damage red cell membranes.
- Results in rigid sickle shaped cells which tend * to cause vaso-occlusion; causes cascade of
- pathological events: Infarction, vasculopathy, * haemolysis, inflammation.
acute clinical manifestatins of sickle cell
anaemia
acure anaemia
infection
painful crises
priapism
Infection in Sickle cell disease?
longterm problems in sickle cell disease
investigations for sickle cell
when to admit to hospital : sickle cell
management principles for sickle cell diagnosis
- Oxygenation.
- Pain relief (within 30 minutes).
- Fluid replacement (PO or IV):
- Reduced tubular concentrating.
- High viscosity worse sickling.
- Red cell transfusion (urgent)
- Broad spectrum antibiotics.
key points about sickle cell disease
meningitis history and examination
- Acuity of onset?
- Any recent infection e.g. viral URTI/herpes?
- Altered behaviour:
- drowsiness/lethargy
- irritability, confusion
- Poor feeding/off feeds; vomiting?
- Photophobia? * Seizures?
- Full/bulging fontanelle (<18 months).
- Neck stiffness, +ve Brudzinski/Kernig signs.
- Focal neurological signs/papilloedema.
differential diagnosis for meningitis
- Bacterialmeningitis.
- Viral meningitis.
- Viral encephalitis.
- Tuberculous meningitis.
- Cerebral abscess.
- Hydrocephalus.
- Non-accidental injury.
bacterial meningitis ABCDE assessment
management of bacterial meningitis
Sepsis 6
Lumbar puncture
lumbar puncture contraindications
Typical changes in the CSF in meningitis or encephalitis
Acute management of bacterial meningitis
complications of bacterial meningitis
meningococcal septicaemia aetiology
VERY HIGH RISK OF MORTALITY
- 12 capsular serotypes; commonest in UK (B,C, W, Y).
- Carried in nasopharynx:
- rate low in infants/young children.
- 25% of adolescents.
- 5-11% of adults.
- 5-11% of adults.
- Droplet spread; needs prolonged close contact.
- Not understood why disease develops in some individuals.
presentation of meningococcal septicaemia
- incubation period of 2-7 days. Prodrome: coryzal (‘flu-like’) illness.
- fever.
- poor feeding, vomiting, diarrhoea. headache, irritable, drowsy, seizures.
- Rash present in only 80% at presentation.
risk factors of meningococal carries becoming unwell
Age, season (Winter), smoking.
Preceding Influenza A infection.
Living in ‘closed’/’semi-closed’ community.
is meningococcal meningitis the same as meningococcaemia
Meningitis can occur with/without septicaemia Septicaemia can occur with/without meningitis
management of meningococcal septicaemia
common causes of seziures
- Febrile convulsions
- Known epilepsy ± acute illness
- Meningitis or encephalitis
- Hypoglycaemia/hypocalcaemia
- Metabolic/Poisoning
- Trauma – accidental or non-accidental
Febrile convulsion
- 6 months to 5 years – no prev. neurology.
- Generalised in nature.
- Less than 15 minutes duration.
- No IC infection/metabolic disturbance.
- Simple or complex.
- Recurrence risk 30-40%.
Infantile spasms
- Age of onset: 3-12 months.
- Sudden violent flexor spasms of head, trunk
and limbs followed by extension of arms. - Last 1-2 seconds; occur multiple/day.
- Often with developmental regression.
- EEG: hypsarrthymia; Rx ACTH, steroids.
Absence Epilepsy
- Age of onset: 4-12 years; girls>boys.
- Sudden onset; last few seconds (<30).
- Associated with automatisms – flickering of
eyes, purposeless movement of eyes/mouth. - EEG: 3 per second (hz) spike and wave.
- Spontaneous remission in adolescence.
investigations for seizure
managment of a seizure
1) ABCDE (DONT EVER FORGET GLUCOSE)
10 mins
2) Benzodiazepine
- IV/ IOacces- Lorazepam
- no IV access- Midazolam (buccal), diazepam (rectal)
10mins
Still fitting?
3) Lorazepaman IV
+- Paraldehyde PR
10 mins
Still fitting?
4) Phenytoin IV/IO Phenobarbitone IV/IO
Still fitting?
5) Rapid sequence induction (RSI) with thiopentone to ge thold of airway
after 30 mins = Status epilepticus
Status epilepticus
A seizure that lasts longer than 5 minutes, or having more than 1 seizure within a 5 minutes period, without returning to a normal level of consciousness between episodes is called status epilepticus
differentials: 6-year-old boy presents to ED with a fever and an acute antalgic gait.
- Transient synovitis.
- Septic arthritis.
- Osteomyelitis.
- Trauma; non-accidental injury.
- Malignancy (leukaemia,neuroblastoma).
- Perthes disease.
- Juvenile idiopathic arthritis.
presentation of septic arthritis
investigations for septic arthritis
management of septic arthritis
Atraumatic limp summary
clinical presentations of dehydration e.g. due to sickness and diarrhoea
history, examination and investigations for dehydration
- Onset, frequency (stools/vomits), duration.
- Number times urinated in past 24 hours.
- Risk factors for dehydration?
- Other family members/contacts unwell?
- Recent foreign travel?
- Consumption of unsafe foods - takeaway, BBQ?
- Clinical evidence of dehydration
- Features suggestive of hypernatraemia
risk factors for dehydration
- <1 year old, especially <6 months old
- Low birth weight
- Signs of malnutrition
- Stopped breastfeeding during illness
- Not offered/not tolerated fluids before
presenting - > 5 episodes of diarrhoea in past 24h – or –
- > 2 vomits in past 24h
managment of dehydration based on severity
presentation of DKA
Early:
Most common – the ‘classical triad’:
* Thirst (excessive drinking/polydipsia).
* Polyuria.
* Weight loss (over short period of time).
Less common:
* Fatigue.
* Enuresis (secondary).
* Polyphagia (excess hunger/eating). * Recurrent infections (e.g., candida)
Late (diabetic ketoacidosis):
* Smell of ketones.
* Nausea and vomiting.
* Dehydration.
* Hyperventilation due to acidosis.
* Abdominal pain.
* Drowsiness.
* Hypovolaemic shock.
* Coma and death.
criteria for diagnosiing T1DM
Pathophysiology of Diabetic Ketoacidosis
management of DKA
types of insulin
