Child Emergency Flashcards
Signs of serious illness
\_\_\_\_\_\_\_\_ 58% \_\_\_\_\_49% \_\_\_\_\_\_\_\_\_\_41% \_\_\_\_\_\_42% \_\_\_\_\_\_\_\_\_\_\_\_\_ 42%
Drowsiness
Pallor
Chest wall retraction
Temperature >38.9°C or
<36.4°C
Lump >2 cm
ABCDEGF of Child emergency
- A irway
- B reathing
- C irculation
- D isability (neurological assessment)
- E xposure
- F luids: in and out
- G lucose
Two main groups of signs are good indicators of
serious illness
Group 1: common features with reasonable risk and indicator of toxicity
Group 2: uncommon features with high
risk requiring urgent referral
Group 1: common features with
reasonable risk and indicator of toxicity
A = poor Arousal, Alertness and Activity
B = Breathing difficulty
C = poor Circulation (persistent pallor, cold legs
to knees)
D = Decreased fluid intake and/or urine output
Group 2: uncommon features with high
risk requiring urgent referral
- Respiratory: ____
- GIT: ____
- CNS: convulsions
- Skin: petechial rash
apnoea, central cyanosis, respiratory grunt
persistent bile-stained vomiting, mass
>2 cm other than hydrocele or umbilical hernia,
significant faecal blood
Inspiratory noises with obstruction — \_\_\_\_\_\_—partial obstruction with fluid — snoring—decreased level of consciousness — \_\_\_\_\_—partial obstruction to larynx or trachea
bubbly noises
stridor
Secondary signs of worsening obstruction
• Increased respiratory rate or effort • Decreased oxygen saturation • Increasing tachycardia • Deterioration of colour • Development of agitation or decreased level of consciousness
Investigations for sick child
Culture and sensitivity
_______________
Full blood examination __________
All with fever
All <4 weeks
Risk factors present
Doctor uncertain
Investigations for sick child
Those on antibiotics
Doctor uncertain
C-reactive protein
Indications for CSF examin
Suspected meningitis (infant drowsy, pale and febrile) Convulsion in febrile child and: • source of fever unknown • receding drowsiness and pallor • infant <6 months, child >5 years • prolonged convulsion (>10 minutes) • postictal phase longer than usual (>30 minutes)
________
is the usual rhythm at the time of arrest.
Asystole or severe bradycardia
How is BLS done outside the hospital
Basic life support outside the hospital
setting is 30: 2 compression ventilation
ratio, including two initial rescue breaths.
The ratio of 30:2 is recommended for all
ages regardless of the number of revivers
present
How to ventilate properly
Ventilate lungs at about 20 inflations/min with
bag-valve-mask or mouth to mask or mouth to
mouth. An Air-viva using 8–10 L/min of oxygen
is ideal if available
If intubation not possible, use a needle
_______ as an emergency
cricothyroidotomy
How to do compressions in children
Use two fingers or thumbs for infants <1 year
and heel of one hand for children 1–8 years.
If >8 years use a two-handed technique
Differences in children’s airways for intubation:
• epiglottis\_\_\_\_\_\_\_ • larynx \_\_\_\_\_ → difficult to intubate ‘blind’ •\_\_\_\_\_\_\_ → cuffed tube not required • shorter trachea → increased risk intubating \_\_\_\_\_\_\_\_\_ • narrow airway → increased airway resistance
longer and stiffer, more horizontal
more anterior
cricoid ring is narrowest position
right main bronchus
Rule for endotracheal tube (ETT) size
(internal diameter in mm
• ETT (mm) = (age in years ÷ 4) + 4
or the size of the child’s little finger or nares
• ETT length (cm) oral = (age in years ÷ 2) + 12;
nasal—add 3 cm
Drugs that can be administered through the ETT
can be considered under the mnemonic NASALS:
N = Naloxone A = Atropine S = Salbutamol A = Adrenaline L = Lignocaine S = Surfactant
Give a single shock instead of stacked shocks
(single shock strategy) for _____
ventricular
fibrillation/pulseless ventricular tachycardia
Where the arrest is witnessed by a health care
professional and a manual defibrillator is available,
________ the first defibrillation attempt
then up to three shocks may be given (stacked
shock strategy) at
Monophasic or biphasic defibrillation:_______
first
shock—2 J/kg, subsequent shocks—4 J/kg.
Children
_____ old are most prone to accidental poisoning
1–2 years
The most common cause of death in comatose
patients is _______
respiratory failure
The common dangerous poisons in the past were
____ and _____
kerosene and aspirin
In a UK study the main cause of deaths from
poisoning were (in order) tricyclics, salicylates,
opioids including _______
Lomotil, barbiturates, digoxin,
orphenadrine, quinine, potassium and iron
In poisoning
The modern trend is away from_______
emesis,
which includes not using syrup of ipecacuanha
What to give within an hour of poisoning
gastric lavage: within 1 hour but also has a
limited place in management
How to give activated charcoal
multiple dose charcoal, 5–10 g every 4 hours
or 0.25 g/kg per hour for 12 hours, is effective
When not to give activated charcoal
never administer activated charcoal in
children with an altered conscious state
without airway protection (use only where
benefits outweigh the risks of aspiration) 7
Contraindications for activated charcoal
- stuporous or comatose
- absent gag reflex (unless endotracheal tube in situ)
- ingestion of corrosives: acids, alkali
- ingestion of hydrocarbons or petrochemicals
Drugs not absorbed by active charcoal
Acids Alcohols (e.g. ethanol) Alkalis (caustics) Boric acid Bromides Cyanide Iodines Iron Lithium Other heavy metals
It is usually limited to iron and lead,
and slow-release drug preparations that don’t bind to
charcoal.
Whole bowel irrigation
What is the antidote?
Amphetamines (cause hypertension
Glyceryl trinitrate IV Sodium nitroprusside
What is the antidote?
Benzodiazepines
Flumazenil
Sodium bicarbonate
What is the antidote?
Beta blockers
Glucagon
Isoprenaline
What is the antidote?
Calcium blocker
Calcium chloride IV or
Calcium gluconate IV
What is the antidote?
Carbon monoxide
Oxygen 100%
Hyperbaric oxygen
What is the antidote?
Cyanide
Hydroxocobalamin
Dicobalt edetate
Sodium nitrite IV
Sodium thiosulphate IV
What is the antidote?
Digoxin
Digoxin-specific
antibodies
Magnesium sulphate
What is the antidote?
Heavy metals (e.g. Pb, As, Hg, Fe)
Chelating agents, e.g.
dimercaprol
What is the antidote?
Heparin
Protamine IV
What is the antidote?
Methanol, ethylene glycol
Ethanol (ethyl alcohol)
What is the antidote?
Organophosphates
Atropine Pralidoxime (2-PAM)
What is the antidote?
Paracetamol
acetaminophen
Acetylcysteine (IV) (effective
within 12 hours) consider
up to 36 hours
What is the antidote?
Phenothiazines
Benztropine
What is the antidote?
Potassium
Calcium gluconate
Sodium bicarbonate
Salbutamol aerosol
What is the antidote?
Tricyclic antidepressants
Sodium bicarbonate IV
What is the antidote?
Warfarin
Fresh frozen plasma
Vitamin
The natural passage of most objects entering the
stomach can be expected. Once the _______ is
traversed the FB usually continues
pylorus
If a blunt FB has been stationary for 1 month
without symptoms, remove at ________
laparotomy
If not in stomach these (especially lithium batteries)
create an emergency if in the oesophagus because
__________
electrical current generated destroys mucous
membranes and perforates within 6 hours (must be
removed endoscopically ASAP).
Febrile Sz
- The commonest cause is an_______
- Commonest age range _____
- Epilepsy develops in about_______of such children
URTI
9–20 months
2–3%
Abx for bact men in children
• ceftriaxone 100 mg/kg up to 4 g, IV statim then
daily for 3–5 days
or
cefotaxime 50 mg/kg up to 2 g, IV statim then 6
hourly for 3–5 days
Abx for bact men in neonates
• ampicillin (or benzylpenicillin) + cefotaxime
Abx for meningococcemia
benzylpenicillin 60 mg/kg IV (max. 1.8 g), 4 hourly
for 3–5 days. Give IM if IV access not possible
or
ceftriaxone 100 mg/kg IV or IM (max. 4 g) statim
then daily for 5 days
Whom to give prophylaxis in pts with meningo
- live in the household and <24 months
- have kissed patient in the previous 10 days
- have attended the same day care centre
How to give meningo prophylaxias
prophylaxis—rifampicin dose: adult — 600 mg bd for 3 days child <1 month—5 mg/kg child >1 month—10 mg/kg give bd for 2 day
A toxic febrile
illness, with sudden onset of expiratory stridor,
should alert one to this potentially fatal condition
Acute epiglottitis
________ is characterised by fever, a soft voice,
lack of a harsh cough, a preference to sit quietly
(rather than lie down) and especially by a soft stridor
with a sonorous expiratory component
Epiglottitis
________ is distinguished by a harsh inspiratory
stridor, a hoarse voice and brassy cough.
Croup
Children with _______usually sit still with their
mouth open, drooling saliva, and their eyes follow
you around the room because limited head movement
protects the compromised airway.
epiglottitis
______________ confirms the
diagnosis of epiglotitis
A swollen, cherry-red epiglottis recognised
on examination of the nasopharynx
Abx for epiglotitis
cefotaxime 25 mg/kg up to 1 g IV for 5 days
8 hourly
or
ceftriaxone 25 mg/kg to max. 1 g/day IV daily for
5 days
______ refers to a symptom complex with a harsh,
brassy cough, usually with an inspiratory stridor and
with or without respiratory difficulty
Croup
Cause of Croup
caused by parainfluenzal and other viruses
e.g. RSV
What grade of croup?
(barking cough, no stridor or stridor at
rest without chest retraction, hoarse voice):
Grade 1 croup
Tx of Gr 1 croup
consider oral steroids (e.g. dexamethasone
- 15–0.3 mg/kg/dose or prednisolone 1 mg/kg/
dose) if stridor and chest wall retraction develop
What grade of croup?
(inspiratory stridor when upset or at
rest with chest wall retractions):
Grade 2 croup
Grade 2 croup Tx
• oral steroids
dexamethasone 0.6 mg/kg
or
prednisolone (tablets or oral solution)1 mg/kg
(2–3 doses) and/or (for children 2 or more years)
budesonide 100 mcg × 20 puffs or 2 mg nebulised
• nebulised adrenaline
What is Gr 3 croup
Severe croup (inspiratory stridor at rest, use of accessory muscles, patient restless and agitated).
What is the first line of tx for gr3 croup
Adrenaline is first-line therapy:
- An acute viral illness usually due to RSV
- The commonest acute LRTI in infants
- Usual age 2 weeks to 9 months
Bronchiolitis
PE of Bronchiolitis
Hyperinflated chest: barrel-shaped, usually
subcostal recession
CXR of bronchiolitis
Hyperinflation of lungs with depression of
diaphragm—but chest X-ray should not be used for
diagnosis or routinely performed
Causes of acute heart failure in children
- congenital (e.g. VSD)
- cardiomyopathy
- tachyarrhythmias
- postprocedural myocardial dysfunction
_______ is necessary in almost every child
where there is a strong suggestion of an inhaled FB.
It is difficult and requires an expert with appropriate
facilities
Bronchoscopy
How to give NE in anaphylaxis
(repeat adrenaline every 5 minutes as necessary)
if no improvement set up a continuous infusion
(1 mg adrenaline in 1000 mL N saline)
Mx of drowning
• decompress stomach with nasogastric tube
• support circulation with _____
• _______
• correct electrolyte disturbances (e.g. hypokalaemia
IV infusion of colloid solution and dopamine 5–20 mc g/kg per minute
mannitol 0.25–0.5 g/kg IV if cerebral oedema
Intraosseous infusion is
preferred to an intravenous cutdown in children
under_____
5 years
Site of Intraosseous infusion
- Adults and children over 5: _______
- Children under 5: ______
distal end of tibia
proximal end of tibia
Characteristic
features include sudden-onset pallor which persists,
episodic crying and vomiting. Rectal bleeding and an
abdominal mass
Intussusception
_________, which appears from 2 weeks
to 3 months of age, should be suspected with
projectile vomiting, acute weight loss and alkalosis
Pyloric stenosis
Bile-stained vomitus indicates urgent referral to
consider possible ___________ and ______
intestinal malrotation and mid-gut
volvulus
Failure to pass meconium beyond 24 hours: may
represent _______
congenital intestinal atresia and stenosis,
meconium ileus or Hirschsprung disease
risk factor for SIDs
Risk factors • Prone sleeping position • Smothered airways (debatable) • Artificial feeding (possible) • Passive smoking (before or after birth) • Hyperthermia or excess warmth • Extreme prematurity <32 weeks • Parental narcotic/cocaine abuse • Intercurrent viral infections
_______or ‘near-miss SIDS’, is defined as a ‘frightening’
encounter of apnoea, colour change or choking. At
least 10% will have another episode
Apparent life-threatening episod
Guidelines for home apnoea monitoring
- ALTE
- Subsequent siblings of SIDS victims
- Twin of SIDS victim
- Extremely premature infants
