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CSI > CSI 18- Acutely Unwell Child (Meningitis) > Flashcards

CSI 18- Acutely Unwell Child (Meningitis) Flashcards

1
Q

How does NICE guidelines define pyrexia ?

What other factors should you consider?

A

“an elevation of body temperature above normal daily variation” but recognises that this is generally accepted as a temperature of 38°C or above.

Ear temp may be 0.3C higher than the one taken in mouth.

MICA says 37.5 for ear!!!

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2
Q

What questions must you ask if a child presents acutely with pyrexia?

A
  • How long has the fever been present?
  • Has the parent/carer been measuring temperature and, if so, by what method?
  • Is there a rash? If so, is it blanching or non-blanching?
  • Are there any respiratory symptoms - eg, cough, runny nose, wheeze?
  • Has the child been clutching at their ears?
  • Has there been excessive or abnormal crying?
  • Are there any new lumps or swellings?
  • Are there any limb or joint problems?
  • Is there any history of vomiting or diarrhoea? Is the vomiting bile-stained or is there any blood in the stool?
  • Has there been any recent travel abroad?
  • Has there been any contact with other people who have infective diseases?
  • Is the child feeding normally (fluids and solids as appropriate)?
  • What is the urine output? Have nappies been dry?
  • How is the child handling? Normal self/drowsy/clingy and so forth?
  • Have there been any convulsions or rigors?
  • Is there any significant past medical history/regular medication/allergy?
  • Is there a history of recent foreign travel, putting the child at increased risk of imported infection?
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3
Q

What are the other points to get from hx

A
  • Level of parental anxiety and instinct (they know their child best).
  • Social and family circumstances.
  • Other illnesses affecting the child or other family members. Has there been a previous serious illness or death due to febrile illness in the family?
  • Has the child been seen before in the same illness episode?
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4
Q

In Examining an unwell child, what are the 1st 2 things you should consider before going on to complete the exam?

A

Assess life-threatening situations: ABCD

Consider sepsis and refer as emergency if suspected

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5
Q

what systems/component MUST YOU examine?

A

Temperature

Look at skin, lips/ tongue colour

Activity levels of child

Resp system

Cardio system

Level of hydration

other features

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6
Q

You are assessing temperature.

What should you keep in mind? (dos and don’t)

A
  • Infants <4 weeks: measure with an electronic thermometer in the axilla.
  • A child aged 4 weeks to 5 years: measure with either an electronic thermometer in the axilla, a chemical dot thermometer in the axilla or an infrared tympanic thermometer.
  • Take parental reported fever seriously.
  • Temperature ≥38°C in an infant aged 0-3 months is a red-light sign.
  • Temperature ≥39°C in a child aged 3-6 months should be considered at least an amber-light sign.
  • Do not rely on the decrease in temperature (or lack of it) following anti-pyretic agents in distinguishing serious from non-serious illness.
  • Do not take the height of the temperature alone as a sign of serious disease in a child older than 6 months.
  • Do not use the duration of fever to predict the likelihood of serious disease except when considering Kawasaki disease.
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7
Q

What do you look for when assessing the Resp system

A

RR: There’s tachypneoa :

  • RR > 60 at age 0-5 months
  • >50 at age 6-12 month
  • >40 more than 1 yr

look for nasal flaring/grunting/chest indrawing

Auscultate for crackles/wheeze

Measure Sats

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8
Q

What are you looking for when examining the Cardio system?

A

Pulse/BP/Auscultate heart / CRT

Tachycardia if:

  • HR> 160 bpm in childe less than 1 yr
  • >150 between 12-24 months
  • >140 , 2-4 yrs
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9
Q

what are you lookinf for when assessing levels of hydration

A
  • Eyes/skin normal?
  • Turgor?/ mucus membranes
  • Cap refill time
    • a CRT of more than 3 seconds is amber
  • Extremities warm or cold?
  • Feeding?
  • Urine output
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10
Q

what are the other features you should examine?

A
  • Rash: if there is a rash, is it blanching or non-blanching?
  • Are there any new lumps?
  • Is there limb or joint swelling or any problem with weight-bearing?
  • Is the fontanelle sunken, normal or bulging?
  • Is there neck stiffness?
  • Are there focal neurological signs/convulsions?
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11
Q

What are the specific diseases you should look out for when assessing an acutely unwell child

A
  • Meningococcal disease
  • Meningitis
  • Kawasaki diseas
  • Pneumonia
  • HSV encephalitis
  • UTI
  • Septic arthritis/osteomyelitis
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12
Q

Give signs for the following specific diseases?

  • Meningococcal disease
  • Meningitis
  • HSV encephalitis
A

Meningococal

  • fever and a non-blanching rash, especially if the child looks ill,
  • there are purpura present (non-blanching lesions >2 mm in diameter),
  • CRT is ≥3 seconds or there is neck stiffness.

Meningitis

  • fever plus
  • any neck stiffness,
  • bulging fontanelle,
  • decreased consciousness or convulsive status epilepticus.
  • Classical signs of meningitis may be absent in infants.

HSV encephalitis : fever plus-

  • focal neurological signs,
  • if there are focal seizures or if there is a reduced level of consciousness.
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13
Q

Give signs for the following specific diseases?

  • Pneumonia
  • UTI
  • Septic arthritis and osteomyelitis
A

Pneumonia

  • Increased RR, chest crackles
  • nasal flaring/ chest in drawing
  • Sats less than 95% on air

UTI

  • consider in any child <3 months with fever.
  • In children older than 3 months, consider, if there is associated
    • vomiting, poor feeding,
    • lethargy,
    • irritability,
    • abdominal pain or tenderness,
    • urinary frequency or dysuria or
    • offensive urine or haematuria.

Septic arthritis/osteomyleitis

  • consider if there is limb or joint swelling
  • non weight bearing
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14
Q

what are the specific signs of Kawasaki disease you should be looking out for

A

consider this if there is fever that has lasted >5 days

Additional features include (can be fewer):

  • Bilateral conjunctival injection without exudate.
  • Erythema of lips or oral and pharyngeal mucosa.
  • Dry cracked lips or strawberry tongue.
  • Change in the extremities (oedema, erythema, desquamation).
  • Polymorphous rash.
  • Cervical lymphadenopathy.
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15
Q

what should you do if there’s fever without an obvious focus

A

Most common cause is viral infection

clinical assessment and urine should be tested in all children with an unexplained fever >38

Abx should not be used empirically for febrile. children without an apparent cause

Use NICE traffic light system to escalate as required

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16
Q

Oultine the traffic system for the following :

  • Colour of skin , tongue etc
  • Activity
A
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17
Q

Oultine the traffic system for the following :

  • Resp system
  • Cardio system
A
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18
Q

Oultine the traffic system for the following :

  • other
A
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19
Q

Outline how you would manage a febrile child remotely

What should you consider

A
  • Hx should be taken from carers
  • ABCD assessed and any immediate life threatening illness suspicion should be referred to emergency care
  • Red traffic features but NO immediate life-threatening illness should be seen by a health prof within 2 hrs
  • Amber - seen urgently but left to clinical judgement
  • Green- manage at home and give advice to parent on how and safety net
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20
Q

Outline managemt by a non-peads practioner (incl GP)

A
  • ABCD assessemnt- emergency if life threatening
  • Clinical assessment and used traffic light system
  • Red features- urgent assessment by a paediatrician
  • Amber but with no specific diagnosis requires urgent assessment to paeds or safety net parent or arrange follow up
  • Green- home management and safety net
21
Q

outline management of specific diseases

A
  • If there is no obvious source of infection, urine should be tested in children presenting with fever.
  • If meningococcal disease is suspected, antibiotics should be given at the earliest opportunity.
22
Q

What advice should you give carer for home care of child

A
  • Give regular fluids: breast milk if the child is breastfed.
  • Monitor for signs of dehydration: sunken fontanelle or eyes, dry mouth, absence of tears, poor appearance, reduced urinary output.
  • Monitor for appearance of rash: advise on how to assess if a rash is non-blanching.
  • Get up in the night to monitor the child.
  • Keep the child away from school or nursery while they have a fever and notify them.
  • When to seek further help:
  • Antipyretic treatment
  • Provide written information- pt leaflet
23
Q

when should they seek further help(safety net)

A
  • if the child has a seizure,
  • develops a non-blanching rash
  • appears less well than when they were last assessed by a healthcare professional,
  • the parent or carer is worried
  • the fever lasts >5 days, the parent o
  • carer is distressed or feels they cannot look after the child.
  • dehyrdation
24
Q

explain the details behind antipyretic medication (management at home0

A
  • tepid sponging is not recommended.
  • Do not underdress or over-wrap children.
  • Give either paracetamol or ibuprofen for discomfort or distress but not for the sole reason of reducing the temperature.
  • One agent can be changed for the other if the child does not respond.
  • If distress persists or recurs before the next dose is due, the agents can be alternated.
  • Do not use both agents simultaneously.
  • Advise parents that antipyretic agents do not prevent febrile convulsions and should not be used specifically for this purpose.
25
Q

What are the most common causative bacteria organisms in meningitis and give any relevant features

A
  • Neisseria meningititdes (COMMENSAL)
  • Streptococcus pneumonia (most common in neonates and gotten from vagina)
  • Heamophilus influenzae (was most common before 1992)
26
Q

what are the non-specific symptoms of :

  • bacterial meningitis
  • Meningococcal disease
  • Meningococcal septicaemia
A
  • fever
  • n/V
  • Headache
  • Non-blanching rash
  • Altered mental state
27
Q

what are the specific symptoms of :

  • bacterial meningitis
  • Meningococcal disease
  • Meningococcal septicaemia
A

Specific for meningitis:

  • Photophobia
  • Kernig sign: with the hips flexed, there is pain/resistance on passive knee extension
  • Brudzinski sign: flexion of the hips when the neck is flexed

Septicaemia

  • Shock
  • Hypotension / Tachycardia
  • Increased CRT

Meningococcal

  • Non-blanching rash (not specific)
28
Q

what are the general specific steps you would take in GP if a child is suspected with meningococcal disease (pre-hospital management)

A

Call 999 – EMERGENCY

ABCD resus

Emergency transfer

Give IM/IV parenteral benzylpenicillin – 300mg if they have no allergy /contraindications

  • Do not do treatment if it will delay hospital transfer
  • IM should be a s proximally as possible

Reassure Mother

Handover to paramedic and paediatric reg

29
Q

outline the CSF result for bacterial meningitis

A
30
Q

outline the CSF result for viral and TB/fungal meningitis

A

N.b Opening pressure depends on the mass of the organism ; measured by calibrated glass tube at the LP

31
Q

Outline the hospital management and Ixs for a pt with meningitis

A
  • Give IV Abx
  • Blood PCR to look for causative organisms - a - result doesn’t rule out meningococcal disease
  • Don’t use skin samples unless in africa
  • CT; good in adult but not for kids for checking ICP
  • Antiprotein C and other coagulation markers
  • LP
32
Q

what are the contraindications of LP

A
  • Respiratory /cardiovascular compromise
  • Raised ICP : normal clinical sign
    • Baby: feel fontanelles
  • Signs of severe sepsis/rapidly evolving rash
  • Infection at site of LP
  • Coagulopathy
  • unequal pupils
33
Q

what does these gram stains show?

A
34
Q

In order to perform LP on a child, they need sedation.

What should you arrange to make this possible

A
  • Peads team and SPR should be ready to perform LP before calling anaesthetists
  • Anaesthetists will need the following
    • Allergy?
    • Med?
    • PMHx
    • Last meal and need to be NBM for 6 hrs prior due to aspiration risk
    • Events: SBAR, IS CHILD WELL? (pews)
35
Q

What are the viral and fungal causative organisms for meningitis

A
  • VIRAL - most common cause
    • Enteroviruses
    • Mumps
    • HSV
    • VZV
    • HIV
  • Fungal
    • Cryptococcus (common cause of meningitis in HIV patients)
36
Q

Specific treatments in the hospital

specify the treatment the following conditions

  1. older than 3 months with suspected bacterial meningitis
  2. younger than 3 months with suspected bacterial meningitis
  3. suspected meningococcal disease
  4. kids travelled outside UK and have prolonged Abx exposure
A
  1. IV ceftriaxone 10 days
  2. IV cefotaxime plus amoxicillin/ampicillin: 14 days
  3. IV ceftriaxone: 7 days
  4. Vancomycin + above
37
Q

Specific treatments in the hospital

specify the treatment the following conditions:

  1. if you must use calcium containing infusions
  2. Suspect TB
  3. HSV meningoencephalitis is suspected
A
  1. DON’T USE ceftriaxone but use cefottaxime
  2. Abx regime for TB
  3. Antiviral (Acyclovir)
38
Q

what are the contraindications for using ceftriaxone?

A

Dont use in babies with:

  • jaundice
  • hypoalbuminaemia
  • acidosis

it exacerbates hyperBR

39
Q

Specific infections in hospital

what are the treatment regimes for kid younger and older than 3 month old for the specific causative organism

A

Older

  • Hib : IV ceftriaxone for 10 days
  • S.pneumonia: IV ceftriaxone for 14 days unless Abx sensitivity shows otherwise

Younger

  • Group B strep: IV Cefotaxime for atleast 14 days and extend if complicated
  • L.monocytogenes: IV amoxicillin/ampicillin for 21 days in total and gentamicin for first 7 days
  • Gram negative bacilli: IV Cefotaxime for at least 21 days
40
Q

what other aspects of management of bacterial meningitis and meningococcal septicaemia should you be aware of?

A

Monitor metabolic disturbances

Raised ICP?

Seizures

Fluid management as required

  • correct using entereal fluids / feed. if IV it should be 0.9% saline with 5% dextrose
41
Q

when should you restrict fluids?

A

there is evidence of:

  • raised intracranial pressure, or
  • increased antidiuretic hormone secretion
42
Q

what is the componet of maintenance fluids for neonates?

A

use glucose 10% and added sodium chloride for maintenance.

43
Q

Outline resus protocol in meningococcal septicaemia in hospital

A

Discuss with paeds intensivist

In shock give 20ml/kg of 0.9% over 5-10 mins (IV or IO)

if persist give 2nd bolus of above or human albumin 4.5%

if it STILL persist:

  • immediately 3rd bolus of above (incl Albumin)
  • call anaesthesist for urgent intubation
  • vasoactive drugs
  • some kids may need larger volume to restore circulation
  • give further boluses
44
Q

Outline vasoactive therapy for shock in meningococcal septicaemia

A

IV adrenaline and/or IV noradrenaline

consider reason why it’s needed such as:

  • persistent acidosis
  • incorrect dilution
  • extravasation

discuss with peads intensivist and follow local /national protocols

45
Q

Outline the guidance for resp support un kids with bacterial meningitis /meningococcal septicaemia

A

if can self ventilate and have signs of resp distress give 15L non-rebreather

airway threatened- prepare for tracheal intubation esp by paeds expert

  • start bag–valve mask ventilation

Beware that they can deteriorate and anticipate aspiration, oedema, worsening shock

46
Q

Apart from threatened airway what are the other indication for tracheal intubation and mechanical ventilation

A

the need for any form of assisted ventilation, for example bag–mask ventilation

  • clinical observation of increasing work of breathing
  • hypoventilation or apnoea
  • features of respiratory failure, including: － irregular respiration (for example, Cheyne–Stokes breathing) － hypoxia (PaO2 less than 13 kPa or 97.5 mmHg) or

decreased oxygen saturations in air － hypercapnia (PaCO2 greater than 6 kPa or 45 mmHg)

  • continuing shock following infusion of a total of 40 ml/kg of resuscitation fluid
  • signs of raised intracranial pressure
  • impaired mental status: － reduced or fluctuating level of consciousness (GCS less than 9 or a drop of 3 or more) － moribund state
  • control of intractable seizures
  • need for stabilisation and management to allow brain imaging or transfer to the paediatric intensive care unit or another hospital.
47
Q

Outline guidelines for use of corticosteroids in pts with suspected bacterial meningitis or suspected meningococcal septicaemia

A

DO NOT use in kids younger than 3 months no matter what

Use only in bacterial meningitis

Give IV dexamethasone 0.15mg/kg to a max of 10mg ASAP if LP shows :

  • frankly purulent CSF
  • CSF white blood cell count greater than 1000/microlitre
  • raised CSF white blood cell count with protein concentration greater than 1 g/litre
  • bacteria on Gram stain.

Discuss with peads senior after 1st dose

If TB is suspected use their guidelines

If dex isn’t given before or with 1st dose of Abx, give withing 4hr

  • DO NOT GIVE MORE THAN 12 HRS
48
Q

Outline guidelines for use of corticosteroids in pts with suspected bacterial meningitis or suspected meningococcal septicaemia

A

DO NOT USE

Only if unresponsive to vasoactive agent :

  • use hydrocortisone 25mg/m2 4D
  • guided by paeds intensivist
49
Q

What adjunctive therapies should you not use?

A

Activated Protein C or recombinant bacterial permeability-increasing protein esp in meningococcal septicaemia

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