Emergencies

Question 1

what is the fluid bolus given in Sepsis?

Answer 1

balanced isotonic crystalloid OR saline 0.9%

Question 2

septic shock in child
A_E assessment

Answer 2

airway - patent?
B- breathing- high flow o2
C- HR,CRT, BP, cap refill, femoral pulse; circulatory shock/BP here

establish VBG
establish IV/IO access
give fluid resus here

D- avpu / glucose
E- rash / temp

Question 3

Sepsis - initial resus
what fluid?
what is the dose?
how long / what time over?

aim? better perfusion

Answer 3

no crackles at lung bases
or hepatomegaly

• means kid is not fluid overloaded

10mL kg balanced crystalloid IV BOLUS over 5-10 mins

reassess

Question 4

if fluid overloads - sepsis?

Answer 4

stop bolus start inotropic support

-adrenaline infusion

Question 5

initial resus principles - sepsis

Answer 5

SEEK HELP

1) fluid bolus - 10ml
2)inotrope - consider
3)correct hypoglycaemia/hypocalcaemia
4)abx broad spec
4)seek ID help

5) call anaesthetist / call picu

Question 6

Sepsis -
signs of fluid refractory shock

how to manage

Answer 6

refractory shock is despite fluid resus there is persistent hypotension

IV/IO
inotrope infusion

adrenaline 0.05-0.3mcg kg

noradrenaline - 0.05mcg

Question 7

DKA criteria?

Answer 7

ketosis - urinary or in plasma >3mmol/l

acidosis- <7.3

blood glucose - >11mmol/l

Question 8

DKA -Resus

Answer 8

A-E

Airway: patent?
B: High flow O2 via non rebreathe mask - 94-98%

C: IV access, take VBG, monitor ECG, identify shock
pulse,HR,RR,BP,Cap refill, femoral pulse

D: raised ICP signs
rising BP with bradycardia
headache
confusion

E: Rash, AVPU, temperature

CALL FOR SENIOR SUPPORT

Question 9

Fluid resus in acutely unwell DKA presentation

there are no signs of shock

what is the fluid bolus?

Answer 9

fluid bolus 10mL kg of ISOTONIC crystalloid or 0.9% NACL over 60 mins

Question 10

Fluid resus in acutely unwell DKA presentation

SIGNS OF SHOCK

what is the fluid bolus?

Answer 10

10ml over 5-10 mins and reassess
can repeat to maximum of 40ml

fluid can be either crystalloid / 0.9% sodium chloride !!

inform PICU

Question 11

DKA - if there are signs of raised ICP?

Answer 11

3% mannitol or sodium chloride
call for senior support asap / PICU / anaesathist

Question 12

DKA - principles of treating

Answer 12

1) Fluid replacement with 40mmol potassium chloride

> unless potassium >5.5

2) Next is insulin to stop ketoacidosis

BUT insulin drives potassium into cells = hypokalaemia - this can cause fatal arrhythmia. So monitor and that is why you give fluid replacement with potassium in DKA paeds

3) Monitor electrolytes / ECG / neurological signs

Question 13

How to correct fluid deficit in DKA?

Answer 13

over 48 hours

1) find out Fluid Requirement

2) find out fluid deficit

Question 14

what is the estimated fluid deficit in DKA?

Answer 14

Mild DKA - 5% fluid deficit
Moderate DKA - 7% Fluid Deficit
Severe DKA - 10% Fluid Deficit

Question 15

how is DKA defined as mild / moderate / severe

to then be able to get the estimated fluid deficit?

Answer 15

pH 7.2-7.9 is MILD

pH 7.1-7.19 is MODERATE

pH <7.1 is SEVERE

in mild DKA - 5% fluid deficit
in moderate 7% fluid deficit
in severe 10% fluid deficit

Question 16

Maintenance fluid calculation?

if a kid weighed 25kg?

Answer 16

First 10kg add 100ml/kg

Next 11-20kg add 50ml/kg

20-75 add 20ml/kg

1) for first 10kg that 1000ml
2)Next 10kg is 500ml
3) last 5kg is 100ml

1600ml/ per day over 24 hours

Question 17

1)Fluid deficit is calculated?

2)if 5% dehydrated 10kg child?

3) if no sign of shock in patient with DKA what do you do to the initial bolus given?

Answer 17

1) % dehydration x weight (kg) x10
in ML

2) 5% x 10 x 10
=500ml

3) Subtract initial fluid bolus from
fluid deficit

so in this patient if they were given 10ml/kg

500-100ml = 400ml is the fluid deficit

Question 18

when is insulin started in DKA?
how is it given?

Answer 18

1-2 hours after IV fluids give insulin infusion

0.05-0.1 units /kg/hour

Question 19

when is glucose given in DKA?

Answer 19

once blood glucose is LESS THAN 14mmol/l add 5% glucose

Question 20

what are the 2 most serious DKA complication that occur in treatment?

Answer 20

Cerebral oedema:
Neuro observations
Watch for signs of raised ICP
Mannitol can be used for managing this but at this point- seek senior support urgently

Hypokalaemia:
cardiac dysfunction
monitor with ECG,
give 40mmol/l KCL with IV fluids
keep monitoring

Question 21

Acute Asthma
Life threatening
signs?

Answer 21

Unable to talk
Silent chest
PEFR <33%
O2 sats <92% on air
cyanosis
hypotension

Question 22

how to manage life threatening Asthma presentation

Answer 22

A-E
Seek / call for senior support - PICU

O2 High flow non rebreathe mask aim for 94-98%

Nebulised salbutamol 2.5-5mg every 20 mins
Ipratropium bromide 250mcg

Review

Oral steroids - 20mg prednisolone / 30-40mg if older than 5 years

IV magnesium bolus

Consider
Repeat / IV steroid if vomiting
Early single IV bolus of salbutamol
Aminophylline if unresponsive child

Question 23

Anaphylaxis

Answer 23

A-E approach

Diagnose:
Airway/Breathing /Circulation problem
skin changes

Call for help
Position - Either lie down / sit to make breathing easier

Give IM adrenaline
High flow O2
pulse, ECG, BP

repeat IM adrenaline after 5 mins
IV fluid bolus

Question 24

Adrenaline in anaphylaxis

> 12 years of age
6-12 years of age
6 months to 6 years
<6 month

Answer 24

IM anterolateral aspect of thigh

500 micrograms - 0.5mL
300 micrograms - 0.3mL
150 micrograms - 0.15mL
100-150 micrograms - 0.1-0.15mL

Question 25

Neonatal resus
chest not moving
heart rate 50

Answer 25

at birth delay cord clamp

1) Dry baby- start clock
2) 30 seconds: Assess tone, breathing and heart rate

3) 60 seconds: open airway and 5 breaths
4)Reassess

5) No chest movement then
consider 2 person airway control
repeat inflation breaths
consider intubation / laryngeal mask

Question 26

Neonatal resus
chest moving
heart rate 50

Answer 26

at birth delay cord clamp

1) Dry baby- start clock
2) 30 seconds: Assess tone, breathing and heart rate

3) 60 seconds: open airway and 5 breaths
4)Reassess

5) slow heart rate <60 min, ventilate for 60 seconds

6) Reassess and start chest compressions (3:1)
ventilate

7) reassess heart rate every 30 seconds