Chapter 3 Structured approach to the seriously ill child Flashcards
Why do infants grunt in respiratory distress?
Expiration against partially closed glottis in attempt to generate PEEP.
Shows severe respiratory distress.
Seen in conditions causing stiff lungs, most often pneumonia and pulmonary oedema.
Raised ICP, abdominal distension and peritonism.
In children with raised intracranial pressure. Will their respiratory rate increase or decrease?
Decreased due to decrease respiratory drive
Name three conditions where a child may be in respiratory failure without an increased respiratory effort
1) exhaustion - preterminal
2) Respiratory depression due to raised intracranial pressure, poisoning or encephalopathy
3) Neuromuscular disease
If a child is hypoxic with bradycardia, what should this signal to you ?
Bradycardia in the setting of hypoxia is preterminal
If central cyanosis is present, what should this signal to you?
Late signs of hypoxia and signals impending respiratory arrest.
Only seen when O2 sats < 70%
What should hypotension signal to you?
Pre-terminal sign, imminent cardiac arrest
What should tachypnoea with increased tidal volume but no recession give a clue to?
Metabolic acidosis
What feautures would suggest cardiac cause of respiratory inadequacy?
1) Cyanosis not correcting with O2
2) Tachycardia out of proportion with respiratory difficulty
3) Raised JVP
4) Gallop rhythm/murmur
5) Enlarged liver
6) Absent femoral pulses
What is the likely management of bacterial epiglottitis or tracheitis?
Intubation (ideally senior anaesthetist) then cefotaxime or ceftriaxone IV
When should you consider inotropes? After how much fluid?
After the 3rd fluid bolus
How much hypertonic saline do you give for raised intracranial pressure?
3ml/kg of 3% saline over 15- 30min
A child has a GCS of E1 V1 M2 they are decerebrating. What does this suggest?
Brain damage in the mid brain area causing:
Extensor posturing
all limbs extended
jaw clenched
neck retracted
A child has a GCS of E1 V1 M3 they are docorticating. What does this suggest?
Brain damage above the midbrain area:
Flexor posturing
arms flexed and adducted
legs and often trunk extended
what rate does the WHO use as a cut off for pneumonia in infants and young children?
60 breaths per min
what does a slow RR indicate in a child when they are unwell?
fatigue
cerebral depression
pre-terminal state
over what age is increased WIB more significant?
6 years old as their chest wall is less compliant. Suggests severe respiratory compromise.
the sternomastoid muscle is used as an accessory respiratory muscle in adults. In children what does it do?
Nothing it is ineffective and just causes the head to bob up and down.
Gasping in a child?
Severe hypoxia and may be a pre-terminal sign.
urine outputs that suggest shock?
<1ml/kg/hr in children
<2ml/kg/hr in infants
are there any neurological problems that take priority over ABC?
No!
consider intubation in any child with a AVPU of?
P or U
what glucose concentration does APLS use?
3ml/kg of 10% dextrose
what can be the other causes of a high temp in a child?
drugs
prolonged seizure
prolonged shivering
what is included in the secondary medical survey?
once observations have been assessed and life threatening conditions have been treated
Focused medical history from child and parents
review of available notes
review of pre-hospital info
clinical examination and specific investigations
Emergency Rx
If ‘bubbly’ noises are heard, the airway is full of secretions
suction
Emergency Rx
If there is a harsh stridor associated with a barking cough and severe respiratory distress
Upper airway obstruction due to severe croup
Nebulised Adrenaline
(Nebulised Budesonide)
Dexamethasone
Emergency Rx
If there is a quiet stridor, drooling and a short history in a sick‐looking child, consider?
Epiglottitis
Tracheitis
Intubation may be required
IV Cefotaxime or Ceftriaxone
With a sudden onset and significant history of inhalation, consider?
FB inhalation
Stridor following ingestion/injection of a known allergen suggests?
Anaphylaxis
6-12 years = 300micrograms
6 months - 6 years = 150micrograms
<6months = 100-150micrograms
In children with suspected duct-dependent congenital heart disease that is unresponsive to O2 treatment or shock Rx. How would you manage them?
Dinoprostone (prostoglandin or PGE2)
or Alprostadil (PGE1)
If there is evidence of raised intracranial pressure (decreasing conscious level, asymmetrical pupils, abnormal posturing and/or abnormal ocular motor reflexes) then the child should undergo: (3)
Ventilation to maintain end‐tidal CO2(ETCO2) 3.5–4.0 kPa (26–30 mmHg) (this is equivalent to arterial PaCO24.0–4.5 kPa (30–34 mmHg)
head in‐line and 20° head‐up position (to help cerebral venous drainage)
Infusion of IV 3% sodium chloride (3 ml/kg) or mannitol 0.25–0.5 g/kg (i.e. 1.25–2.5 ml/kg of 20% solution IV over 15 minutes)
dexamethasone dose for vasogenic oedema surrounding a brain mass?
0.5mg/kg 6 hourly
the pulmonary vascular bed is relatively muscular in infancy - what impact does this have?
increases the tendency for pulmonary vasoconstriction to occur causing hypoxia
this can lead to right to left shunting, ductal opening (in the early neonatal period)
ventilation - perfusion mismatch and further hypoxia
why can a child in the first 1-2months of life present with low respiratory rate or apnoea with infection?
there is a paradoxical inhibition of respiratory drive in the first 1-2months of life.
in infants the lung volume at end expiration is similar to closing volumes - what impact does this have?
it increases the tendency for small airway closure and hypoxia
how long is foetal Hb present for and what impact does this have?
4-6months of age
the O2 dissociation curve is shifted to the left = O2 given up less readily in the tissue
= infants are more prone to tissue hypoxia
describe croup treatment and doses
Dexamethasone 0.15-0.6mg/kg
or
Prednisolone 1-2mg/kg
or
Budesonide 2mg
if severe upper airway concerns
5ml of 1:1000 adrenaline
Describe a moderate asthma exacerbation
Describe a severe asthma exacerbation
Describe a life threatening asthma exacerbation
provide 3 historical features associated with life threatening or severe asthma flares
- long duration of symptoms and or regular nocturnal awakening
- poor response to treatment already given in this episode
- severe course of previous attacks e.g PICU admission
