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Yr 4 - Paediatrics > Common ED Presentations: Paeds > Flashcards

Common ED Presentations: Paeds Flashcards

1
Q

Children are especially sensitive to dehydration 2ary to what?

A

D&V

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2
Q

Features of dehydation in paeds?

A

1) Tachycardia

2) Reduced skin turgor

3) Reduced urine output

4) Sunken eyes

5) Dry mucous membranes

6) Altered responsiveness

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3
Q

When preparing for the arrival of a sick child, it helps to have an idea of the doses of emergency drugs.

The WETFLAG mnemonic is used to remember the appropriate doses of drugs, fluids and electricity.

Describe the WETFLAG mneumonic

A

Weight: estimated as (Age+4) x 2.

Energy: energy (joules) for cardiac arrest = 4 x weight (kg)

Tube: endotracheal tube size (cm) = (Age/4) + 4

Fluids: fluid bolus = 10mls / kg isotonic fluid (caution in some cases)

Lorazepam: 0.1mg / kg (max 4mg)

Adrenaline: 10mcg/kg (0.1ml/kg of 1:10000 solution)

Glucose: 2mls/kg (10% dextrose)

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4
Q

Cardiac arrest in paeds can be caused by decompensated respiratory failure or decompensated circulatory failure.

Decompensated respiratory failure can be caused by obstruction.

What are 3 causes?

A

1) Foreign body

2) Asthma

3) Croup

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5
Q

Decompensated respiratory failure can be caused by respiratory depression.

What are 3 causes?

A

1) Convulsions

2) Poisoning

3) Raised ICP

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5
Q

Decompensated circulatory failure can be caused by fluid distribution.

What are 3 causes?

A

1) Septic shock

2) Anaphylaxis

3) Cardiac failure

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6
Q

Decompensated circulatory failure can be caused by fluid loss.

What are 3 causes?

A

1) Vomiting

2) Burns

3) Blood loss

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7
Q

Head tilt chin lift in infants (<1y)?

A

Typically into neutral position (i.e. not a tilt).

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8
Q

What are some signs of respiratory distress in paeds?

A

1) Subcostal recession

2) Intercostal recession

3) Tracheal tug

4) Grunting

5) Nasal flare

6) Head bobbing

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9
Q

In what 3 situations may increased respiratory effort be absent?

A

1) Exhaustion

2) Central respiratory depression

3) Neuromuscular disease

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10
Q

What are 3 pre-terminal respiratory signs?

A

1) Silent chest

2) Cyanosis

3) O2 sats <85% air

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11
Q

Resus fluid guidelines for paeds?

A

Fluid bolue 10mls/kg and assess response.

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12
Q

Is grunting a sign of mild, mod or severe respiratory distress?

A

Severe

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13
Q

Is sternal recession a sign of mild, mod or severe respiratory distress?

A

Severe

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14
Q

Hypotension in paeds?

A

This is a PRE-TERMINAL sign.

Children have a robust CVS physiological reserve, meaning they will compensate well initially but may deteriorate rapidly.

I.e. may be clinically shocked with normal BP.

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15
Q

What are some features that indicate the need for an urgent head CT in paeds (within 1h)?

A

1) Suspicion of NAI

2) Post-traumatic seizure

3) GCS <14 on initial assessment or, for babies less than 1 year, a paediatric GCS <15

4) GCS <15 at 2 hours post injury

5) Suspected open or depressed skull fracture or tense fontanelle

6) Any sign of basal skull fracture

7) Focal neurological deficit

8) For babies under 1 year, a bruise, swelling or laceration of more than 5 cm on the head.

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16
Q

What are some signs of a basal skull fracture?

A

1) haemotympanum

2) panda eyes

3) CSF leakage from ear/nose

4) Battle’s sign

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17
Q

What is haemotympanum?

A

Presence of blood in the middle ear cavity (behind TM).

Usually 2ary to trauma.

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18
Q

when is insulin started in DKA in paeds?

A

After 1 hour of fluid therapy

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19
Q

What are 2 types of incomplete fractures seen in children?

A

1) Greenstick fracture

2) Torus (buckle) fracture

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20
Q

What is a greenstick fracture?

A

An incomplete fracture where one side of the cortex is affected, but the bone does not break all the way through.

This can be compared to when a green twig is bent and splinters on one side.

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21
Q

What is a torus (buckle) fracture?

A

An incomplete fracture with a small bump or buckle in the cortex of the bone.

Commonly seen in the distal ulna and radius in children.

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22
Q

What classification is commonly used to describe the different types of growth plate fractures?

A

The Salter-Harris classification

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23
Q

Describe the Salter-Harris classification for growth plate fractures

A

I Slipped: fracture passes through the growth plate itself

II Above: fracture extends above the growth plate (through the metaphysis)

III Lower: fracture extends below the growth plate (through the epiphysis)

IV Through: fracture extends through the metaphysis, growth plate and epiphysis

V Rammed: a crush injury which compresses the growth plate

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24
Q

Typically, what are 3 causes of a wheeze in paeds?

A

1) Bronchiolitis

2) Asthma

3) Viral wheeze

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25
Q

What is bronchiolitis caused by?

A

RSV

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26
Q

What age does bronchiolitis typically present in?

A

<2 y/o

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27
Q

Symptoms of bronchiolitis?

A

1) Cough
2) Wheezing
3) Increased work of breathing
4) Difficulty feeding

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28
Q

Mx of bronchiolitis?

A

There is no specific treatment for bronchiolitis, and these patients are managed symptomatically.

Note - XR and blood tests are unnecessary in mild/moderate cases, and bronchodilators such as salbutamol do not work in bronchiolitis.

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29
Q

Use of salbutamol/bronchodilators in viral wheeze vs bronchiolitis?

A

1) Viral wheeze - indicated

2) Bronchiolitis - not indicated

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30
Q

1st line Abx for empirical treatment of suspected neonatal sepsis/meningitis (<1months)?

What would you add if you were concerned about Listeria?

A

IV benzylpenicillin + gentamicin

+ amoxicillin

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31
Q

1st line Abx for empirical treatment of suspected sepsis in 1-3 month olds?

A

IV cefotaxime

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32
Q

1st line Abx for empirical treatment of suspected sepsis/meningococcal disease in >3 month olds?

A

IV ceftriaxone

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33
Q

Possible investigations in a septic screen?

A

1) Blood cultures

2) Urine sample

3) CXR

4) LP

5) Viral nose swabs

6) Bloods: FBC, CRP, glucose, U&Es, LFTs

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34
Q

3 key causes of meningitis & sepsis in neonates?

A

1) GBS

2) E. coli

3) Listeria (less common)

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35
Q

4 key causes of meningitis in older child?

A

1) Viral (e.g. enteroviruses such as coxsackie)

2) Meningococcal

3) Pneumococcal

4) Haemophilus

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36
Q

What are some complications of meningitis?

A

1) Cerebral palsy in <2y

2) Deafness (sensorineural hearing loss)

3) Epilepsy

4) Coning & death

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37
Q

Give some features of severe asthma

A

1) O2 <92%

2) PEF 33-50%

3) Inability to complete full sentences

4) HR >125 in a patient >5 y/o

5) RR >30 in a patient >5 y/o

38
Q

Give some features of life-threatening asthma

A

1) O2 sats <92%

2) PEF <33%

3) Features: exhaustion, cyanosis, hypotension, silent chest, poor respiratory effort or confusion.

39
Q

Stepwise management of acute asthma attack in children

A

1) Inhaled salbutamol via a spacer

2) Add nebulised ipratropium bromide in severe cases (or in cases refractory to salbutamol)

3) Early use of steroids e.g. prednisolone 30-40mg for 3-5 days

4) Severe cases: magnesium, IV salbutamol, aminophylline

40
Q

What is the most common organism causing croup?

A

Parainfluenza virus

41
Q

What is croup?

A

A viral URTI typically affecting young children between 6 months to three years of age.

42
Q

What score is frequently used to assess the severity of croup and guide treatment?

A

Westley croup score

43
Q

Mx of croup?

A

1) Avoid overstimulating the child (including using a tongue depressor

2) Single dose of oral dexamethasone

3) More severe cases: nebulised adrenaline, admission to hospital

44
Q

What are 3 differentials for a child presenting with stridor?

A

1) Foreign body

2) Croup

3) Epiglottitis

45
Q

What are some causes of abdo pain in children?

A

1) Mesenteric adenitis

2) Appendicitis

3) Constipation

4) UTI

5) Testicular torsion

6) Intussusception

7) DKA

8) Others: gastritis, lower lobe pnuemonia, ovarian torsion, ectopic, hernia

46
Q

What is the pain in mesenteric adenitis 2ary to?

A

2ary to inflammation of the mesenteric lymph nodes.

47
Q

What does mesenteric adenitis typically follow?

A

An URTI

48
Q

Purpose of maintenance vs replacement vs resuscitation fluids?

A

Maintenance - required if the current oral intake is not sufficient to remain hydrated e.g. if NBM.

Replacement - required if there is an EXISTING FLUID DEFICIT and the oral route is not possible or impractical.

Resuscitation - required if the patient is SHOCKED.

49
Q

What are some examples where replacement fluids may be required?

A

1) Prolonged poor oral intake

2) Vomiting

3) Diarrhoea

4) Increased insensible losses (e.g. fever, excessive sweating)

5) Diabetic ketoacidosis (DKA)

6) Burn injuries

50
Q

What are some causes of hypovolaemic shock (5)

A

1) Gastroenteritis

2) Burns

3) DKA

4) Heatstroke

5) Haemorrhage

51
Q

What are some causes of distributive shock? (3)

A

1) Sepsis

2) Anaphylaxis

3) Neurological injury (neurogenic)

52
Q

What are 2 causes of cardiogenic shock?

A

1) Congenital heart disease

2) Arrhythmia

53
Q

What are 3 causes of obstructive shock?

A

1) Cardiac tamponade

2) Tension pneumothorax

3) Congenital heart disease

54
Q

What is hypotension a sign of in children?

A

Hypotension is a sign of decompensated shock and indicates that the child is critically unwell.

55
Q

What is usually the first line maintenance fluid in children >28 days old?

A

Isotonic crystalloids + 5% glucose

E.g. 0.9% saline + 5% glucose

56
Q

What formula is used to calculate routine maintenance fluids for children (>28 days old)?

A

Holliday-Segar formula:

100 ml/kg/day for the first 10kg of weight
50 ml/kg/day for the next 10kg of weight
20 ml/kg/day for weight over 20kg

57
Q

E.g. Calculate the 24-hour maintenance fluids and hourly infusion rate for a 40kg child

A

100 x 10 = 1000

50 x 10 = 500

20 x 20 = 400

=1900 ml/24h

= 79 ml/hr

58
Q

What fluids are typically used for replacement in children (>28 days)?

A

Isotonic crystalloid that contains sodium with added glucose.

E.g. 0.9% sodium chloride + 5% glucose.

If there are ongoing losses (e.g. diarrhoea, vomiting) supplement with potassium (e.g. 10 mmol/L).

59
Q

How can percentage dehydration be calculated in children?

A

Either clinically or by weight.

60
Q

How can percentage dehydration be calculated by weight?

A

If a recent and accurate weight for the child is available from a time that they were well, the % dehydration can be calculated by comparing this ‘well weight’ with their current weight.

The difference between the two weights represents the volume of fluid that has been lost.

The formula for calculating this is:

% dehydration = (well weight (kg) - current weight (kg)) / well weight then x 100

61
Q

Once percentage dehydration is known, a fluid deficit can be calculated.

How is this calculated?

A

Fluid deficit (ml) = % dehydration x weight (kg) x10

62
Q

Replacement fluids are given alongside routine maintenance fluids over a 24-hour period.

How is this calculated?

A

Total fluid requirement (mL) = maintenance fluids (mL) + fluid deficit (mL)

63
Q

A child who weighs 12kg is 5% dehydrated. Calculate their total fluid requirement over 24 hours

A

Fluid deficit = 5% dehydration x 12 x 10 = 600ml

Maintenance = 1000ml + 100ml = 1100ml

Total fluid requirement = 1100 + 600 = 1700ml /24h = 71ml/hr

64
Q

What is the standard fluid for resus in paeds?

A

0.9% saline with no additives via IV or IO (if IV access is not possible) in a standard bolus of 10 mL/kg over <10 minutes.

65
Q

What are some exceptions where smaller boluses of resus fluids may be required?

A

1) Neonatal period (<28d)

2) DKA

3) Septic shock

4) Trauma

5) Cardiac pathology (e.g. heart failure)

66
Q

Do you need to subtract the resuscitation boluses from the total 24-hour fluid requirements?

A

No

67
Q

For a shocked child, what % dehydration can you assume?

A

10% dehydration based on body weight.

68
Q

How to calculate total fluid requirements in shocked children?

A

Therefore, to calculate the total 24-hour fluid requirements we would use the following two formulae:

Fluid deficit (mL) = 10% dehydration x weight (kg) x 10
Total fluid requirement (mL) = maintenance fluids (mL) + fluid deficit (mL)

69
Q

What can rapid correction of severe hyponatraemia lead to?

A

Central pontine myelinolysis

70
Q

What can rapid correction of severe hypernatraemia lead to?

A

Cerebral oedema

71
Q

Estimated child’s weight?

A

Estimated weight = (age + 4) x 2

72
Q

Calculation for deficit fluids in paeds fluid prescribing?

A

Deficit = % dehydration x weight (kg) x 10

73
Q

What fluid is used for deficit & maintenance fluids in paeds prescribing?

A

0.9% NaCl + 5% dextrose

74
Q

What is Kernig sign?

A

Indiciates meningitis

Patient supine, with hip flexed 90 degrees. Knee cannot be fully extended.

75
Q

What is Brudzinski skin?

A

Indicates meningitis.

Passive flexion of neck causes flexion of both legs and thighs.

76
Q

Prophylactic mx of household in bacterial meningitis?

A

Single dose of ciprofloxacin

77
Q

Most common organisms causing bacterial meningitis in neonates vs infants?

A

Neonates:
- GBS
- E. coli
- Listeria (rare)

Infants:
- N. meningitidis
- S. pneumoniae
- H. influenzae

78
Q

Is a LP indicated in meningococcal sepsis?

A

NO (due to deranged clotting)

79
Q

Give some contraindications to LP

A

1) Raised ICP:
- focal neurology
- bradycardia
- HTN
- abnormal pupils
- abnormal posturing
- GCS <9

2) Deranged clotting:
- platelets <100
- any abnormal result on clotting screen

80
Q

If a raised ICP is suspected ,what imaging should be performed to look for signs of meningeal inflammation?

A

CT head and neck

81
Q

What Abx are indicated for suspected meningitis in infants aged <3m?

A

Cefotaxime (+ amoxicillin) for 14d

82
Q

What Abx are indicated for suspected meningitis in children aged >3m?

A

Ceftriaxone for 14d

83
Q

What is included as part of treatment for bacterial meningitis in those aged >3m to reduce the chance of sensorineural hearing loss?

A

Dexamethasone

Hearing test recommended in 4-6 weeks

84
Q

At what age is it recommended to include dex in mx of bacterial meningitis?

A

> 3m

85
Q

What is the most common complication of bacterial meningitis?

A

Sensorineural hearing loss

86
Q

Give some features of 10% dehydration (i.e. shocked)

A
  • pale or mottled
  • sunken eyes
  • hypotension
  • prolonged CRT
87
Q

Give some features of 5% dehydration (not shocked)

A
  • dry mucous membranes
  • tachycardia
  • tachypnoea
  • NORMAL CRT
  • NORMAL BP

i.e. some evidence of dehydration but normal BP and CRT

88
Q

Should you substract fluid bolus from fluid deficit when prescribing?

A

ONLY if worried about fluid overload

89
Q

What is max weight for using formula to calculate maintenance fluids?

A

75kg

90
Q

What is it important to do after every 500ml bag when prescribing fluids?

A

Reassess:
- fluid status assessment
- U&Es
- fluid balance chart

91
Q

Over how long do you correct fluid deficit in DKA?

A

Over 48h (not normal 24h) due to risk of cerebral oedema.

92
Q

Definitive mx of NEC?

A

Emergency laparotomy

93
Q
A

Yr 4 - Paediatrics (78 decks)

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