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Y5 Paediatrics > Emergencies > Flashcards

Emergencies Flashcards

1
Q

Define Sepsis.

A
  • Systemic inflammatory response syndrome = generalised inflammatory response, defined by the presence of ≥2 criteria (abnormal temperature or WCC must be one of the criteria):
    • Abnormal core temperature (<36 or >38.5°C)
    • Abnormal HR (>2 S.D. above normal for age, or less than 10th centile for age if child aged < 1 years)
    • Raised RR (>2 S.D. above normal for age, or mechanical ventilation for acute lung disease)
    • Abnormal WCC in circulating blood (above or below normal range for age, or >10% immature cells)
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2
Q

What are the red flags for sepsis in children?

A
  • Hypotension
  • Blood lactate >2mmol/L
  • Prolonged capillary refill >5 seconds
  • Pale/mottled or non-blanching (purpuric) rash
  • Oxygen needed to maintain saturations >92%
  • RR >60 min-1 or >5 below normal, or grunting
  • AVPU = V, P or U
  • Abnormal behaviour
    • Excessively dry nappies
    • Lack of response to social cues
    • Significantly decreased activity
    • Weak
    • High-pitched or continuous cry
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3
Q

What defines Sepsis, Severe Sepsis or Septic Shock?

A
  • Sepsis = SIRS in the presence of infection
  • Severe sepsis = sepsis in presence of CV dysfunction, respiratory distress syndrome, or dysfunction of ≥2 organs
  • Septic shock = sepsis with CV dysfunction persisting after at least 40 mL/kg of fluid resuscitation in one hour
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4
Q

What are the common causative organisms of sepsis in children?

A
  • Early onset neonatal = GBS, Escherichia coli, L. monocytogenes
  • Late onset neonatal = Coagulase-negative Staphylococcus
    • i.e. Staphylococcus epidermidis
  • Other causative organisms:
    • Staphylococcus aureus (Coagulase +ve)
    • Non-pyogenic streptococci
    • Streptococcus pneumoniae
    • Neisseria meningitidis
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5
Q

What are the appropriate investigations for suspected sepsis in children?

A
  • Clinical suspicion - diagnosis cannot be delayed
  • Sepsis 6
    • Blood cultures
    • Urine output
    • Fluids
    • Antibiotics
    • Lactate
    • Oxygen
  • LP in the following
    • <1m old
    • 1-3m who appear unwell
    • 1-3m with WCC <5 or >15 x109/L
  • Bloods
    • Clotting (as DIC can feature in sepsis)
    • VBG (including glucose and lactate)
    • Blood culture
    • FBC
    • CRP (N.B. takes 12-24hrs to rise)
    • U&Es and creatinine
  • Imaging - CXR
  • Urine dipstick on MSU
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6
Q

What is the management of meningococcal sepsis in children?

A
  • Sepsis 6 within 1 hour + continuous monitoring
    • Review by ST4 or above (<30 minutes) and then a consultant (<1 hour)
  • IV access
  • IV fluid resuscitation
  • 20mL/kg 0.9% NaCl bolus
  • Antibiotics within 1hr → follow local guidelines:
    • If meningococcal sepsis
      • IM benzylpenicillin + ambulance (GP)
      • IV cefotaxime (in hospital)
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7
Q

What is the management of non-meningococcal sepsis in children?

A
  • Sepsis 6 within 1 hour + continuous monitoring
    • Review by ST4 or above (<30 minutes) and then a consultant (<1 hour)
  • IV access
  • IV fluid resuscitation
  • 20mL/kg 0.9% NaCl bolus
  • Antibiotics within 1hr → follow local guidelines
    • Early onset <72 hours = GBS, L. monocytogenes, E. coli
      • benzylpenicillin / ampicillin + gentamicin
    • Late onset >72 hours = CoNS (S. epidermidis)
      • ampicillin / vancomycin + gentamicin / cefotaxime
    • >1 month
      • cefotaxime / ceftriaxone / piperacillin / meropenem
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8
Q

What is the management of sepsis with necrotising enterocolitis in children?

A
  • Sepsis 6 within 1 hour + continuous monitoring
    • Review by ST4 or above (<30 minutes) and then a consultant (<1 hour)
  • IV access
  • IV fluid resuscitation
  • 20mL/kg 0.9% NaCl bolus
  • Antibiotics within 1hr → follow local guidelines:
    • metronidazole - active against anaerobic bacteria
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9
Q

What are the signs in cold shock?

A
  • CRT >2s
  • Reduced peripheral pulses
  • Cool mottled extremities
  • Narrow pulse pressure
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10
Q

What are the signs in warm shock?

A
  • Flash CRT
  • Bounding peripheral pulses
  • Warm extremities
  • Wide pulse pressure
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11
Q

What are the signs and symptoms of meningitis in a child?

A
  • Bulging fontanelle, hyperextension of neck and back
  • Headache
  • Photophobia
  • Neck stiffness
  • Fever
  • Kernig’s sign – pain on leg straightening
  • Brudzinski’s sign – supine neck flexion à knee/hip flexion
  • Lethargy
  • Altered consciousness/Drowsiness
  • Seizures
  • Non-blanching rash (80% of meningococcal)
  • HR starts high to compensate ischaemia in brain
    • HR then drops as baroreceptors in heart sense high BP (from HR)
  • Raised ICP symptoms (late signs) = Cushing’s Triad:
    • High BP
    • Low HR
    • Irregular RR
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12
Q

What are the appropriate investigations for childhood meningitis?

A
  • Sepsis 6
  • LP
    • CT head before LP if concerns of raised ICP
  • Blood culture
  • Bloods
    • FBC, CRP, U&E and glucose
  • Coagulation profile
  • Further immunological analysis (complement deficiency) if >1 episode of meningococcal meningitis
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13
Q

What are the causes of meningitis in children?

A
  • Neonatal - 3 months
    • GBS
    • E. coli and other coliforms
    • Listeria monocytogenes
  • 3 months - 6 years
    • Neisseria meningitidis
    • Strepococcus pneumoniae
    • Haemophilus influenza
  • >6 years
    • Neisseria meningitidis
    • Strepococcus pneumoniae
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14
Q

What is the management of childhood bacterial meningitis?

A
  • Antibiotics
    • Child <3m old:
      • IV cefotaxime
      • IV amoxicillin / ampicillin
    • Child >3m old:
      • IM benzylpenicillin, STAT
        • If pen allergy = moxifloxacin & vancomycin
      • IV ceftriaxone:
  • Steroids/Dexamethasone – if CSF shows
    • Purulent CSF
    • WBC >1,000/uL
    • Raised CSF WCC + protein >1g/L
    • Bacteria gram stain
    • >1m old & H. influenzae
    • NOT MENINGOCOCCAL
  • Mannitol - reduce ICP
  • IV saline sodium chloride 0.9%
  • Notify HPU
  • Treat contacts (ciprofloxacin) and offer further support
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15
Q

What follow-up should be offered to children who had meningitis?

A
  • Review patient 4-6w after discharge to discuss long-term potential complications
    • Hearing loss → audiological assessment
    • Orthopaedic, skin, psychosocial complications
    • Neurological/development problems
    • Renal failure
  • Purpura fulminans = haemorrhagic skin necrosis from DIC → acute/fatal, thrombotic disorder, manifest as blood spots/bruising/discolouration of skin
    • Needs FFP, debridement or amputation
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16
Q

What is the management of viral meningitis?

A
  • Discharge home - after tests to exclude bacterial causes
    • With supportive therapy (i.e. fluids)
  • Safety net
17
Q

What are the common causes of viral meningitis?

A
  • Coxsackie Group B
  • Echovirus
18
Q

What is the route of encephalitis infection?

A
  • Direct invasion of cerebellum by neurotoxic virus
    • e.g. HSV
  • Post-infectious encephalopathy of delayed brain swelling following neuroimmunological response to antigen
  • Slow virus infection
    • Most common UK:
      • Enterovirus
      • Respiratory viruses (influenza)
      • Herpes
        • >70% mortality from untreated HSV encephalitis
    • Other = HIV, chickenpox, bacteria & fungus (very rare), mosquitos, ticks, rabies
19
Q

What are the signs and symptoms of encephalitis in children?

A
  • Bulging fontanelle, hyperextension of neck and back
  • Headache
  • Photophobia
  • Neck stiffness
  • Fever
  • Kernig’s sign – pain on leg straightening
  • Brudzinski’s sign – supine neck flexion à knee/hip flexion
  • Lethargy
  • Altered consciousness/Drowsiness
  • Seizures
  • Non-blanching rash (80% of meningococcal)
  • HR starts high to compensate ischaemia in brain
    • HR then drops as baroreceptors in heart sense high BP (from HR)
  • Raised ICP symptoms (late signs) = Cushing’s Triad:
    • High BP
    • Low HR
    • Irregular RR
20
Q

What are the appropriate investigations for childhood encephalitis?

A
  • Sepsis 6
  • LP
    • CT head before LP if concerns of raised ICP
  • Blood culture
  • Bloods
    • FBC, CRP, U&E and glucose
  • Coagulation profile
  • MRI - hyperintense lesions, oedema, BBB breakdown
  • Virus PCR
  • Further immunological analysis (complement deficiency) if >1 episode of meningococcal meningitis
21
Q

What are the contraindications to a LP?

A
  • Cardiorespiratory instability
  • Focal neurological signs
  • Signs of raised ICP → coma, high BP, low HR
  • Coagulopathy
  • Thrombocytopenia
  • Local infection at LP site
  • Causes undue delay in starting ABx
  • Meningococcal meningitis
22
Q

What is the management of encephalitis?

A
  • IV acyclovir (high-dose) 3 weeks
    • HSV is a rare cause but complications are major, so treat empirically
  • Supportive care – fluids, ventilation, etc.
  • Other:
    • CMV = add in ganciclovir and Foscarnet
    • VZV = acyclovir/ganciclovir
    • EBV = acyclovir
23
Q

What is the most common cause of anaphylaxis in children?

A

85% due to food allergy

24
Q

What are the signs and symptoms of anaphylaxis in children?

A
  • Airway → swelling, hoarseness, stridor
  • Breathing → high RR, wheeze, cyanosis, SpO2 <92%
  • Circulation → pale, clammy, low BP, drowsy, coma
  • Skin → urticaria/angioedema
25
Q

What is the management of childhood anaphylaxis?

A
  • ABCDE approach and call for help
    • BLS might be needed if unresponsive/not breathing
  • IM Adrenaline
    • Given in thigh
    • Assess response after 5 minutes and repeat if needed
  • Monitoring and additional treatment
    • Establish airway + high-flow O2
    • IV fluids - 20mL/kg crystalloids
    • IV Chlorpheniramine
    • IV Hydrocortisone
    • Salbutamol - if wheeze
26
Q

Describe the neonatal resuscitation guidelines.

A
  1. Dry baby
  2. Within 30s = assess tone, RR, HR and colour → consider SpO2 and ECG monitoring
  3. Within 60s if not breathing = open airway → 5 inflation breaths
    1. Reassess = if no increase in HR, look for chest movement → if chest NOT moving → re-check head position, suction airway, other airway manoeuvres → repeat 5 inflation breaths, check for chest movement
    2. Reassess → repeat 5 inflation breaths until chest movement seen
  4. Chest moves, HR slow (<60bpm) and ventilate for 30s [rate: 15 over 30s]
  5. Chest moves, HR slow (<60bpm), Chest compressions + ventilation
  6. Reassess HR every 30s: if HR not detectable/slow (<60bpm), consider venous access and drugs
    1. NaCl (fluid resuscitation)
    2. Adrenaline (1 in 10,000; 0.5mL/kg)
    3. Dextrose
    4. NaHCO3 (for metabolic acidosis)
27
Q

Describe the Apgar score.

28
Q

What ratio of compressions : breaths should be used in neonates?

29
Q

What ratio of compressions : breaths should be used in children?

30
Q

What ratio of compressions : breaths should be used in adults?

31
Q

If HR does not increase and poor chest movements continue after tracheal intubation, what should be considered?

A
  • Displaced tube - in oesophagus or right main bronchus
  • Obstructed tube - i.e. meconium
  • Patient
    • Tracheal obstruction
    • Lung disorders (lung immaturity, ARDS, pneumothorax, diaphragmagmatic hernia)
    • Shock from blood loss
    • Perinatal asphyxia or trauma
    • Upper arrays obstruction: choanal atresia
  • Equipment failure - gas supply exhausted/disconnected
32
Q

Describe paediatric BLS.

A
  1. Are they unresponsive?
  2. Shout for help
  3. Establish an airway
  4. Look, listen and feel for breathing
  5. Give 5 rescue breaths
  6. Check for signs of circulation (brachial and radial pulses)
  7. 15 chest compressions (100-120 bpm): 2 rescue breaths (15: 2)

Y5 Paediatrics (26 decks)

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