Chapter 3 Structured approach to the seriously ill child

Question 1

Why do infants grunt in respiratory distress?

Answer 1

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.

Question 2

In children with raised intracranial pressure. Will their respiratory rate increase or decrease?

Answer 2

Decreased due to decrease respiratory drive

Question 3

Name three conditions where a child may be in respiratory failure without an increased respiratory effort

Answer 3

1) exhaustion - preterminal
2) Respiratory depression due to raised intracranial pressure, poisoning or encephalopathy
3) Neuromuscular disease

Question 4

If a child is hypoxic with bradycardia, what should this signal to you ?

Answer 4

Bradycardia in the setting of hypoxia is preterminal

Question 5

If central cyanosis is present, what should this signal to you?

Answer 5

Late signs of hypoxia and signals impending respiratory arrest.
Only seen when O2 sats < 70%

Question 6

What should hypotension signal to you?

Answer 6

Pre-terminal sign, imminent cardiac arrest

Question 7

What should tachypnoea with increased tidal volume but no recession give a clue to?

Answer 7

Metabolic acidosis

Question 8

What feautures would suggest cardiac cause of respiratory inadequacy?

Answer 8

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

Question 9

What is the likely management of bacterial epiglottitis or tracheitis?

Answer 9

Intubation (ideally senior anaesthetist) then cefotaxime or ceftriaxone IV

Question 10

When should you consider inotropes? After how much fluid?

Answer 10

After the 3rd fluid bolus

Question 11

How much hypertonic saline do you give for raised intracranial pressure?

Answer 11

3ml/kg of 3% saline over 15- 30min

Question 12

A child has a GCS of E1 V1 M2 they are decerebrating. What does this suggest?

Answer 12

Brain damage in the mid brain area causing:

Extensor posturing
all limbs extended
jaw clenched
neck retracted

Question 13

A child has a GCS of E1 V1 M3 they are docorticating. What does this suggest?

Answer 13

Brain damage above the midbrain area:

Flexor posturing
arms flexed and adducted
legs and often trunk extended

Question 14

what rate does the WHO use as a cut off for pneumonia in infants and young children?

Answer 14

60 breaths per min

Question 15

what does a slow RR indicate in a child when they are unwell?

Answer 15

fatigue

cerebral depression

pre-terminal state

Question 16

over what age is increased WIB more significant?

Answer 16

6 years old as their chest wall is less compliant. Suggests severe respiratory compromise.

Question 17

the sternomastoid muscle is used as an accessory respiratory muscle in adults. In children what does it do?

Answer 17

Nothing it is ineffective and just causes the head to bob up and down.

Question 18

Gasping in a child?

Answer 18

Severe hypoxia and may be a pre-terminal sign.

Question 19

urine outputs that suggest shock?

Answer 19

<1ml/kg/hr in children
<2ml/kg/hr in infants

Question 20

are there any neurological problems that take priority over ABC?

Answer 20

No!

Question 21

consider intubation in any child with a AVPU of?

Answer 21

P or U

Question 22

what glucose concentration does APLS use?

Answer 22

3ml/kg of 10% dextrose

Question 23

what can be the other causes of a high temp in a child?

Answer 23

drugs
prolonged seizure
prolonged shivering

Question 24

what is included in the secondary medical survey?

Answer 24

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

Question 25

Emergency Rx
If ‘bubbly’ noises are heard, the airway is full of secretions

Answer 25

suction

Question 26

Emergency Rx
If there is a harsh stridor associated with a barking cough and severe respiratory distress

Answer 26

Upper airway obstruction due to severe croup

Nebulised Adrenaline
(Nebulised Budesonide)

Dexamethasone

Question 27

Emergency Rx
If there is a quiet stridor, drooling and a short history in a sick‐looking child, consider?

Answer 27

Epiglottitis
Tracheitis

Intubation may be required

IV Cefotaxime or Ceftriaxone

Question 28

With a sudden onset and significant history of inhalation, consider?

Answer 28

FB inhalation

Question 29

Stridor following ingestion/injection of a known allergen suggests?

Answer 29

Anaphylaxis

6-12 years = 300micrograms

6 months - 6 years = 150micrograms

<6months = 100-150micrograms

Question 30

In children with suspected duct-dependent congenital heart disease that is unresponsive to O2 treatment or shock Rx. How would you manage them?

Answer 30

Dinoprostone (prostoglandin or PGE2)
or Alprostadil (PGE1)

Question 31

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)

Answer 31

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)

Question 32

dexamethasone dose for vasogenic oedema surrounding a brain mass?

Answer 32

0.5mg/kg 6 hourly

Question 33

the pulmonary vascular bed is relatively muscular in infancy - what impact does this have?

Answer 33

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

Question 34

why can a child in the first 1-2months of life present with low respiratory rate or apnoea with infection?

Answer 34

there is a paradoxical inhibition of respiratory drive in the first 1-2months of life.

Question 35

in infants the lung volume at end expiration is similar to closing volumes - what impact does this have?

Answer 35

it increases the tendency for small airway closure and hypoxia

Question 36

how long is foetal Hb present for and what impact does this have?

Answer 36

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

Question 37

describe croup treatment and doses

Answer 37

Dexamethasone 0.15-0.6mg/kg

or

Prednisolone 1-2mg/kg

or

Budesonide 2mg

if severe upper airway concerns

5ml of 1:1000 adrenaline

Question 38

Describe a moderate asthma exacerbation

Answer 38

Question 39

Describe a severe asthma exacerbation

Answer 39

Question 40

Describe a life threatening asthma exacerbation

Answer 40

Question 41

provide 3 historical features associated with life threatening or severe asthma flares

Answer 41

1. long duration of symptoms and or regular nocturnal awakening
2. poor response to treatment already given in this episode
3. severe course of previous attacks e.g PICU admission