Acutely Ill Child Flashcards
what cause should be considered for obesity in very overweight child with short stature
endocrine cause
what are the concerning features of a child witha UTI
- younger
- frequent
- E coli pathogens
- FH of renal disease
- poor growth and general health
- poor urinary flow
- urinating problems
- constipation
- spinal abnormality
- raised BP
- abdominal mass
encopresis
passage of normal stools in abnormal places
treatment of constipation
laxatives, food and drink attention, toileting behaviour advice
what is a red flag concerning passage of meconium
delay in passage of meconium >24 hours after birth may signal intesintal obstruction
features of CF in neonate
- Meconium ileus – surgical emergency
- Abnormally prolonged jaundice
- Malabsorption, steatorrhoea, failure to thrive
- Recurrent chest infections
bristol stool chart
headache red flags
- headache on waking
- worse with coughing or bending
- assoicated vomiting, especially in morning
- thinking raised ICP?
- visual disturbance
- gait disturbance
- CN palsy
red flags for cardiac syncope
- known congenital heart disease
- during exercise/when supine
- FH of sudden death, prolonged QT or HCM
- preceded by palpitations
- heart murmur or other CV abnormalities
5 associated symptoms with murmurs
- breathlessness
- blue
- pale
- sweaty
- poor feeding
red flag symptoms for murmurs
- diastolic - systolic is innocent
- loud - grade ≥3
- associated thrill
- harsh
- radiate widely
- other symptoms
- poor growth
- FH
- syncope
- sweating
- pallor
- poor feeding
innocent murmurs
- systolic, soft, short, symptomless, standing/sitting (vary with position), low intensity, 2nd left interspace, medial to apex, beneath either clavicle
specific childhood murmurs:
- coarctation of aorta
- VSD
- ASD
- pulnonary stenosis
- Coarctation of aorta: Ejection systolic murmur that can be heard through to the back
- VSD: Pansystolic murmur
- ASD: Ejection systolic murmur, splitting of 2nd heart sound
- Pulmonary stenosis: Ejection systolic heard at left upper parasternal edge
compare food intolerance to allergy
- food allergy is a type I IgE mediated reaction - occurs rapidly
- food intolerance is a delayed reaction, and has more varied symptoms
what is measured on a childs head
occipitofrontal circumference
respiratory rate in children
signs of work of breathing
- Tracheal tug
- Nostril flare
- Accessory muscle use
- Intercostal recession
- Sternal recession
- Grunting
what are common surgical problems in children up to one year
- intussception
- volvulus
- incarcerated hernia
what are common surgical problems in children from 2-5 years
- intuscception
- volvulus
- appendicitis
what are common surgical presentations in children from 6 to 18
- appendicitis
- trauma
- testictular trauma
- ovarian torsion
what should not be used to routinely measure temperature in children aged 0-5
oral and rectal routes
measuring temperature in children <4 weeks
electronic thermometer in the axilla
measuring temperature in children aged 4weeks to 5 years
- Electric thermometer in axilla
- Chemical dot thermometer in axilla
- Infra-red tympanic thermometer
what is childrens sitting height like
proportionally more
how do childrens heads differ
relatively large and prominent occiput
sepsis in children
initial clinical presentation may be non-specific, and may progress to organ failure and shock very rapidly
bronchiolitis
- inflammation of the bronchioles
- RSV, also metapneumovirus
clinical features of bronchiolitis
- dry cough, wheezing, fever, grunting
- intercostal/sternal in drawing in severe cases
- hyperinflation
- atelectasis
treatment of bronchiolitis
supportive
croup
- Laryngotracheobronchitis – infection of any of this area
- Usually viral, can be bacterial
- Caused by parainfluenzae virus
- oral steroid treatment
features of croup
- barking cough – severely distressed and cough associated with a harsh sound while breathing. Signs of moderate respiratory distress.
- narrowing of air column and hypopharynx distension - steeple sign on x ray
mangement of croup
oral steroids
widespread wheeze and clinical/family history of atopy etc
asthma
pertussis presentation
- inspiratory whoop/barking cough
- this can be described as the child seeming unable to breath after coughing fit
- caused by forced inspiration against a closed glottis
what does bilious vomiting indicate
initial sign of intestinal obstruction, with/out abdominal distension
how does viral gastoenteritis present
- diarrhoea and may cause vomiting and abdominal pain
what is the most common cause of viral gastroenteritis
rotavirus
typically accompanied by fever
treatment of viral gastroenteritis
usually self limiting
the main risk is dehydration so give oral rehydration solutions
what can often occur for a while after viral gastroenteritis
bloating, abdominal pain, watery stools after drinking milk
presentation of pyloric stenosis
- Presents as two lumps in the upper abdomen, visibly peristalsing.
- Child will be vomiting as the pyloric muscle is closing down the pathway from the stomach to the duodenum. Projectile vomiting typically follows meals by 30 minutes, and the infant is hungry afterwards.
- Constipation and dehydration may also be present
- Hypochloraemic, hypokalaemic alkalosis due to persistent vomiting
at which age does Pyloric Stenosis usually present
2-6 weeks
infantile colic
- presentation
- age
- 2-6 weeks
- paroxysms of crying
- normal examination
cows milk protein intolerance
diarrhoea proceeding vomiting
what is the most common cause of chronic diarrhoea in children
cows milk protein intolerance
galactosaemia
- autosomal recessive metabolic condition that presents with failure to thrive and vomiting
- sugar galactose
how may galactosaemia present
detected by newborn Guthrie test
oil drop cataracts noted on examination
presentation of Intussusception
- pain, drawing legs up to abdomen and then a pahse of limpness and relaxing
- sausage shaped abdominal mass that is palpable
- crying, colic
- currant jelly stool and bullseye appearance on US
most common cause of Intussusception in children
lymphoid hyperplasia due to rotavirus
malrotation
childs intestines are not in the normal position
what may malrotation lead to
- volvulus
- complete twisting of a loop of intestine
- obstruction of blood supply leading to infarction
- can become gangrenous
how does volvulus present
- acutely, abdominal pain, distension and constipation
- green/yellow vomit - bilious
how does malrotation present (and at what age)
- usually before one year
- present with intermittent symptoms of obstruction:
- green/yellow vomit
- crying and fussy
- feeding intolerance
- lethargy
- swollen, tender abdomen
- fever
- tachycardia and tachypnoea
investigation of malrotation/volvulus
abdominal X ray is first line
- Child vomiting, small amounts, effortless, after almost every feed
- Gaining weight appropriately
- No other abnormalities/excessive crying etc.
- mild GOR
what is the meconium
the first stool that a child has, thick and sticky
what does delay in pasage of teh first stool by 24 hours indicate
intestinal obstruction
meconium ileus
- child’s stool is thicker and stickier than usual so creates a blockage in the ileum
- earliest signs are abdominal distension, bilious vomit and no passage of meconium
what do most children with meconium ileus also have
CF
what is required for assessment of jaundice
well lit room
presentation of jaundice
- pale stool, dark urine
- yellow skin that doesnt blanch
what is the cause of jaundice in a 5 day old baby that has no other abnormalities
physiological - baby is adapting to using its own liver
define prolonged jaundice
longer than 14 days in term infants, and 21 days in preterm infants
what can cause prolonged jaundice
obstructive jaundice
pathological cause of jaundice in the first 24 hours
- hepatitis, ABO incompatibility, sepsis, G6PD deficiency (suspect in likely genetic cases)
pathological cause of jaundice from 24h to 2 weeks
- haemolysis, polycythaemia, infection (can be acquired during birth e.g. STI, UTI), dehydration, gut obstruction
pathological causes of jaundice 2 weeks after birth
- poor milk intake
- infection
- hypothyroid
- biliary atresia
investigation of jaundice in infant
LFT, bloods
what can be used to treat physiological jaundice
phototherapy
complication of jaundice
a prolonged increase in bilirubin can cause it to cross the BBB where it is toxic and can cause bilirubin encephalopathy
epiglottitis
- Epiglottitis is an inflammation of the epiglottis with the potential to cause airway compromise, and should be treated as a surgical emergency until the airway is examined and secured.
-
Clinical presentation: drooling, short history, unwell, high fever, audible stridor
- Tachypnoea, tachycardia
- Cervical lymphadenopathy
x ray of epiglottitis
thumb print sign on x ray
management of epiglottitis
- Treat with ceftriaxone, as H. influenzae B is often ß-lactamase resistant (amoxicillin usually), and this is a severe situation
which investigations should be avoided in epiglottitis
- Avoid endoscopy if suspected. Do not touch with tongue depressor
presentation of meningitis
- Purpuric rash
- Photophobic
- Headache, stiff neck
- Fever, vomiting, irritability, lethargy
- prolonged cap refill
investigations of meningitis
- FBC
- blood culture
- lumbar puncture
- imaging
- blood glucose and coagulation screen are often used in 2y care for those with suspected meningitis
what must be done before a lumbar puncture
clotting screen
when would a lumbar puncture be performed for meningitis
- contraindicated in meningococcal septicaemia and any signs of raised ICP
- eg bulging fontanelle
management of meningitis
- ABCDE, ABx, steroids
- notify public health
identification of meningococcal rash and its implications
- glass tumbler test
- implies significant septicaemia
investigations of suspected NAI
- bloods
- bone density DEXA scan and clotting
- plain X ray - full skeletal survey
- to look for old breakages
which 3 professions need to be contacted in suspected NAI
- social worker
- child protection
- paediatrician
risk factors for NAI
- Low birthweight
- Mum<30
- Unwanted pregnancy
- Stress
- Poverty
features that raise suspicion of NAI
- Inconsistent / changing history of events
- Discrepancy of history between parents / carers
- History not consistent with injury
- Injuries not consistent with age of child e.g. non-walking child
- Multiple bruises of varying ages
- Atypical injuries e.g. cigarette burns, genital injuries, torn frenulum, dental injuries, lower limb and trunk burns
- Rib fractures – particularly those of the posterior ribs
- Metaphyseal fractures in infants
- Torn frenulum
which fracture in particular raises suspicion of NAI
posterior ribs
tetralogy of fallot
low oxygenation of blood due to mixing through VSD - cyanosis on first day of life
continuous machine like murmur below left clavicle
patient ductus arteriosus
what is the ductus arteriosus a remnant of
ligamentum arteriosum
egg shaped ventricles
transposition of great vessels
2 signs of coarctation of the aorta
- rib notching on CXR
- radio femoral delay
