Acutely unwell child Flashcards
What is important to prepare for a paediatric resuscitation?
WETFLAG
Weight - (age+4) x2 in Kg
Energy - 4 joules/kg
Tube - (age/4) + 4 = mm
Fluids - 20ml/kg bolus
Lorazepam - 0.1mg/kg
Adrenaline - 0.1ml/kg
Glucose - 2ml/kg
What are some key signs of increased work of breathing in children?
Recession - subcostal, intercostal, tracheal tub
Sniffing the morning air position
Lethargy
What are the key ideas of a child with stridor?
An upper airway problem
Usually inspiratory but can be biphasic
What are some common causes of acute stridor in children?
Viral croup
Epiglottitis
Bacterial tracheitis
Foreign body
Anaphylaxis
What are the common causes of chronic stridor?
Laryngomalacia
Congenital airway abnormality
Birthmarks
Tumours
Vocal cord dysfunction
What is the most common cause of viral croup?
Parainfluenza A and B
What is the common cause of epiglottitis?
Haemophilius Influenza B
What should be included when assessing the airway of a child?
Look - conscious level, chest movement, drooling, swelling
Listen - vocalisation, snoring, stridor (supraglottic), stertor (snoring during sleep airway constriction in NP or OP), silent.
Feel - expired air
Describe the pattern seen in a CXR of a child with an airway obstruction.
What is the theory behind this?
Decreased opacity on the side of the obstruction
Caused by air trapping - ball valve effect enables the child to inhale but they can not exhale - leads to air trapping.
Note this may also be accompanied with a change from wheeze to silence as the obstruction passes further down into the lungs.
What are the signs of a laryngeal impaction?
Choking
Gagging
Hoarseness
Aphonia
Cyanosis
What are the signs of tracheal impaction?
Inspiratory stridor
Coughing
What are the key features of a foreign body ingestion/inhalation?
Peak 1-2yrs
Coins most common
Risk management - high risk object or airway comprise
Metal detector
May use x-ray
What foreign objects are concerning for ingestion in a child?
Button batteries
2 or more magenets
How to tell the difference between a button battery and a coin on ingestion?
Button battery - has a halo sign
Coin - same throughout
What are the concerning signs on this CXR of a 2-year-old who has swallowed a magnet?
More than one magnet
Gassless abdomen
Gastric and duodenal gas with air fluid levels
Suggests a bowel perforation
What is the key difference in symptoms between bronchiolitis and viral induced wheeze?
Bronchiolitis - wet inflamed lungs with secretions - gradually more severe, initial worse than VIW
Viral induced wheeze - bronchoconstriction -> starts at low severity, gradual rise, then sudden rise to high severity.
How does the age of the child influence the most likely cause of a wheeze?
Bronchiolotits most common in infants
Viral wheeze most common in pre-school
Asthma most common in school aged.
How should you assess the breathing of a child?
Effort = RR, recession, noises, gruting, accessory, nostril flaring, gaspring
Efficacy = chest expansion, auscultation, pulse oximetry.
Effect = HR, skin colour, mental status
What is grunting as breathing noise?
Expiration against a partially closed glottis in an attempt to increase airway pressure and prevent atelectasis.
What is the first line treatment for acute asthma?
- Bronchodilators - sulbutamol MDI 10 puffs or Nebs if O2 required
+/- ipratropium bromide nebuliser - Corticosteroid - oral prednisolone/dex, IV hydrocortisone if PO not possible
What are the second line treatment for Acute asthma management?
IV bronchodilators - IV magnesium, aminophylline, salbutamol
Regular IV corticosteroids - 6 hourly hydrocortisone.
When should intubation be considered for an acute asthma scenario?
SpO2 <92% despite high flow/face mask
Hypercapnia - CO2>6kPa.
Reduced conscious level
Poor air entry/silent chest.
What are some cardiovascular signs to be assessed in children?
Heart rate - bradycardia is pre-terminal
Pulses - including femoral
BP - Hypotension is a very late sign
CRP
Murmurs
Hepatomegaly, JVP, oedema
What are some ways of measuring end organ affects in children?
Tachypnoea
Skin - mottling, peripheral, temperature
Mental status - agitation, drowsiness, unconscious
Urine output
What are some signs of clinical dehydration in children?
Irritable or lathergic
Decreased urine output
Dry mucus membranes
Cap refill < 2s
Eyes sunken
Tachycardia
Tachypnoea
What are the key signs of shock in a paediatric case?
Reduced consciousness
Decreased urine output
Pale or mettled
Cool peripheries
Dry mucous membranes
Prolonged cap refill
Eyes grossly sunken
Tachycardia
Hypotension
Tachypnoea.
What are the vascular access options in paediatric?
Peripheral IV cannula
Intraosseous access
Central lines - PICC, midline.
What are the indications/contraindications for intraosseous access in paediatrics?
When IV access is difficult or not possible promptly.
Contraindications - long bone fracture, cellulitis, recent orthopaedic procedure in the planned area within the last 24hrs.
What is the plan for fluid bolus during paediatric resus?
10ml/kg crystalloid
Reassess and repeat 40-60ml/kg
- Balanced isotonic e.g plasmalyte
- 0.9% NaCl
- Dextrose
What should be assessed for disability for a child?
Consciousness - AVPU, GCS
Pupils - PEARLA
Glucose
Posutre and tone - hypotonia, decorticate, decerebrate, meningis (arched backwards - head and neck)
What is the basic treatment algorithm for the treatment of status epilepticus?
Five minutes after seizure onset - 1st benzodiaepine
Five minutes later - 2nd benzo
Five minutes later - IV levetiracetam
Ten minutes later - RSI/phenytoin/phenobarbitone
What is important to check for exposure in children?
Temperature (particularly in under 3months)
Abdomen
Injuries and bruising
Rashes - allergy (urticaria, sepsis petechiae vs purpura)
What are the big five to watch out for in collapsed neonate?
- Sepsis
- Cardiac
- Metabolic
- Surgical/abdominal
- Non-accidental injury
What are the key clinical features of child with an inhaled foreign body?
Coughing paroxysms
Wheezing
Decreased breath sounds
Sudden onset choking or gaggin
Stridor (if above the vocal cords)
Cyanosis/resp distress
Tachypnoea/tachycardia
