Acutely ill child

Question 1

Initial rapid Assement of a seriosuly unwell child (A-E)
just headings for now, but what kind of things are you looking for in:

Airways and Breathing?

Answer 1

• Effort of breathing
• RR and rhythm
• Stridor and wheeze
• Ausculation
• Skin colour

Question 2

Initial rapid Assement of a seriosuly unwell child (A-E)
just headings for now, but what kind of things are you looking for in:

Circulation?

Answer 2

• Heart rate
• Pusle Volume
• Cap refill
• Skin temp

Question 3

Initial rapid Assement of a seriosuly unwell child (A-E)
just headings for now, but what kind of things are you looking for in:

Disability?

Answer 3

• Conscious level
• posture
• pupils

Question 4

Initial rapid Assement of a seriosuly unwell child (A-E)
just headings for now, but what kind of things are you looking for in:

Exposure?

Answer 4

• fever
• Rash
• Bruising

Question 5

Airway assessment in a baby / child: once you have looked, listened and felt for airway patency. What manoevures can you use? What considerations for an infant vs a child?

Answer 5

• Head tilt chin lift.

Infant vs children
* * anatomical differences mean you want the degree of tilt to be neutral in an infant whereas in a child you want a ‘sniffing positon

• • If this does not work - jaw thrust

Question 6

What adjuncts could you use for airway in a child in hospital?

Answer 6

• naso-pharyngeal airways
• Guedel airways

Question 7

In a conscious child what might stridor or a hoarse voice indicate? What should you do?

Answer 7

• Indicate a compromised airway
• senior help / anaesthetic urgently

Question 8

What is stridor? Causes of stridor?

Question 9

Breathing assesssment of an acutely ill child - 3 categories we are assessing

Answer 9

1.Assess the effort of breathing
* ‘How much work is going into breathing?’

2.Assess the efficacy of breathing
* Efficacy: ‘What are they achieving in terms of air movement and gas exchange?’

3. Assess the effects of respiratory failure
   * ‘What is the effect of respiratory inadequacy on the rest of the body?’

Question 10

Breathing: Assessing the effort of breathing. What looking for?

Answer 10

• RR (e.g. raised: airway, lung, metabolic acidosis)
• look for signs of respiratory distress: grunting, nostril flaring, tracheal tug intercostal /subcostal/ sternal recession (accessory muscle use)
• listen for gasping, stridor, wheeze, and grunting.

Question 11

What is the significance of gasping in an unwell child?

Answer 11

gasping is a late sign of severe hypoxia.

Question 12

Normal respiratory rate ranges for children?

Answer 12

Question 13

Why might some children despite being hypoxic not have signs of increased resp effort?

Answer 13

1. Those who have had severe respiratory problems for some time and have become fatigued. Exhaustion (seen in life threatening asthma) is a pre terminal sign.
2. Neuromuscular disease – such as muscular dystrophy
3. Central respiratory depression (from raised intracranial pressure, poisoning or encephalopathy)

Question 14

Breathing: Assess the efficacy of breathing - what looking for?

Efficacy: air movement and gas exchange

Answer 14

• chest expansion?
• auscultation of the chest for air entry (view alongisde 02 sats)
• SpO2 sats
• ‘silent chest’ is a very worrying sign.

Question 15

Breathing: what might asymmetrical air entry and bronchial breath sounds inmdicate?

Answer 15

pneumonia

Question 16

Breathing: what might a wheeze and reduced air entry indicate?

Answer 16

acute asthma

Question 17

Breathing: Assess the effects of respiratory failure: what looking for?

‘What is the effect of respiratory inadequacy on the rest of the body

Answer 17

• Assess mental status
• measuring HR (↑ with hypoxia, but bradycardia is a pre-terminal sign)
• skin colour (hypoxia causes pallor, and cyanosis is a late sign).
• Reduced breathing effort and gasping may indicate exhaustion (a pre-terminal sign), cerebral depression, or neuromuscular disease.

Question 18

Breathing: Hypoxia will initially lead to ____?____ . However, if this is prolonged / severe it will lead to_____?_____

Answer 18

Hypoxia will initially lead to tachycardia . However, if this is prolonged / severe it will lead to bradycardia

Question 19

Breathing: cyanosis is visible with saturations below ____?____ and again is a ____?____ sign

Answer 19

cyanosis is visible with saturations below 70% and again is a late and pre terminal sign

Question 20

Breathing: Hypoxia or hypercapnia may lead to what signs in a child? How might this manifest when examining them?

Answer 20

Hypoxia or hypercapnia will lead to agitation or drowsiness

This may present as the child who will not cooperate with examination and seems very distressed or alternatively, unusually quiet and withdrawn.

Question 21

Breathing: Interventions after identifying any child with resp difficulty or hypoxia….

Answer 21

• high flow oxygen (15litres/min) through an oxygen mask with a reservoir bag.
• use a bag-valve mask if inadequate respiratory effort, consider intubation and ventilation as appropriate.

Question 22

Circulation: Assessment - what looking for?

Answer 22

• HR (bradycardia is a late sign of cardiovascular failure)
• Pulse volume
• Capillary refill
  BP and skin T°. BP maintained until shock is advanced, so hypotension is a pre-terminal sign.
• Look for circulatory failure: tachypnoea, mottled cold skin, poor urine output (defined as <2mL/kg/hr in infants or <1mL/kg/hr in children aged >1y)
• agitation
• drowsiness.

Question 23

Circulation Assessment: What signs to look out for a child that might indicate a cardiac cause for the shock>

Answer 23

• cyanosis despite O2
• ↑ JVP
• heart murmurs
• enlarged liver.

Question 24

Circulation: Interventions for acutely ill child

Answer 24

• venous / IO access and give a 20ml/kg bolus of 0.9% sodium chloride.
• Further boluses should be guided by reassessment and inotropic support considered if more than two boluses are needed (i.e. 60ml/kg)
• Note in DKA - initial bolus is 10ml/kg due to the risk of cerebral oedema.
• Blood samples e.g. FBC, U&Es, CRP, blood culture, venous gas (with lactate), glucose and ammonia

conisder IO access early if hard to cannulate

Question 25

Disability: what looking for ?

Answer 25

• AVPU score (where A is alert, V is responds to voice, P is responds to pain and U is unresponsive) or paediatric GCS
• Floppy - severe illness
• Stiff posturing e.g. decorticate (flexed arms, extended legs) or decerebrate (extended arms and legs) suggests serious brain dysfunction.
• Pupil size and response
• Bedside BM
• Consider raised ICP in any child with depressed conscious level - HTN and bradycardia indicates impending coning.

Question 26

Disability: Interventions

Answer 26

• Consider intubation to stabilise the airway in any child with a conscious level graded as P or U.
• Treat hypoglycaemia with a bolus of 2ml/kg 10% glucose IV or IO, followed by a glucose infusion to prevent recurrence.
• In cases of suspected raised ICP consider mannitol and neuroprotective measures.

Question 27

Exposure: what looking for?

Answer 27

• temp
• rashes (eg meningococcal disease, anaphylaxis)
• bruising/injuries
• surgical scars

Question 28

Once immediately life threatening problems have been addressed, what move onto in assesment of acutely unwell child?

Answer 28

• Reassessing the response to initial resuscitative measures
• Taking a focused history from parent/witness etc
• detailed secondary assessment - including systems based examinations
• Further investigations – these may include laboratory blood tests, ECG, radiographs or other imaging such as CT

Question 29

When assessing the appearance of a child what does the TICLS mneumonic stand for?
a structured way to spot an unwell / abnormally behaving child

Answer 29

Tone – the newborn should have a normal flexed tone; the 6 month old baby who sits up and controls her head; the toddler cruises around the room.

Interactiveness – Does the 2 month old have a social smile? Is the toddler interested in what is going on in the room?

Consolability – A child who cannot be consoled at some point by his mother is experiencing a medical emergency until proven otherwise.

Look/gaze – Does the child track or fix his gaze on you, or is there the “1000-yard stare”?

Speech/cry – A vigorously crying baby can be a good sign, when consolable – when the cry is high-pitched, blood-curling, or even a soft whimper, something is wrong.

Question 30

Sick Baby: 5 DDX for a presentation of a sick baby with vague / non localising signs?

Neonatal period (<28 days of age) and young infancy (< 3months ) = the most common time for congenital conditions to present and highest susceptibility for infection

Answer 30

Question 31

Presentation of sepsis in baby?

You must always consider sepsis in any unwell infant (<3 months)

Answer 31

• irritability, ‘off feeds’, vomiting and diarrhoea, lethargy (not waking for feeds), not wetting nappies, high pitched cry, rapid or shallow breathing, apneoas, seizures or abnormal movements.

Question 32

Clinical features on examination for sepsis?

Answer 32

• tachycardia, tachypnea, fever (>38°C) or hypothermia, hypotension, poor perfusion, respiratory distress, distended abdomen, bulging or tense fontanelle, pallor, mottled skin and decreased conscious level.

Question 33

birth risk factors for neonatal infection?

Answer 33

• maternal fever or known infection in labour
• prolonged rupture of membranes over 24 hours
• Group B Streptococcus infection confirmed in this pregnancy

Question 34

Congenital heart disease often presents in early infancy (often not picked up on scans)

Red flags in history….

Answer 34

poor weight gain, breathlessness (especially during feeding), sweating (again may be during feeding), blue episodes or episodes of pallor

Question 35

Clinical features of Congenital heart disease on examination

Answer 35

• tachycardia
• tachypnea (Resp distress may be present, but tachypnea without respiratory distress is considered a red flag for cardiac disease)
• cyanosis
• pallor
• enlarged liver
• bibasal fine crepitations
• heart murmur or absent femoral pulses.
• check for differences in saturations and blood pressure between the right arm (pre-ductal) and right leg (post-ductal).

Question 36

With any unwell child - what monitoring will they need?

Answer 36

Oxygen saturations (plus CO2 monitoring if intubated)
Pulse rate and rhythm
Blood pressure
Urine output
Core temperature

Question 37

Breathing: A child has a bubbling sound when examine chest what diagnosis does it point to and what emergency treatment?

Answer 37

Question 38

Breathing: on examination a child has harsh stridor and a barking cough

diagnosis?
treatment?

Answer 38

Croup

Oral dexamethesone
nebulised budenosdie or Adrenaline

Question 39

What are signs of upper airway obstruction?

Answer 39

stridor, marked dyspnoea, drowsiness, subcostal/suprasternal recession, drooling of saliva, difficulty speaking, and cyanosis. Any of these warn of impending obstruction.

Question 40

Breathing: find soft stridor, drooling and fever in a sick looking child

diagnosis?
treatment

Answer 40

Bacterial tracheitis or epiglottitis

Intubation by anaesthetist followed by IV antibiotics

Question 41

What is stridor?

Answer 41

high-pitched inspiratory noise. It occurs in croup, acute epiglottitis, inhaled FB, laryngeal trauma, laryngomalacia (‘congenital laryngeal stridor’)

Question 42

breathing: you find a child has Sudden onset stridor with history of inhalation

diagnosis?

treatment?

Answer 42

Inhaled foreign body

Laryngoscopy for removal

Question 43

breathing: a child has Stridor following ingestion or injection of a known allergen

diagnosis ?
Treatment?

Answer 43

Anaphylaxis

IM adrenaline