Emergencies Flashcards
Vital signs Infants
RR 30-40
HR 110-160
BP 80-90
Vital signs Young Children
RR25-35
HR 95-150
BP 85-100
Vital signs Older Children
RR 20-25
HR 80-120
BP 90-110
Causes of shock
Hypovolaemia .e.g. sepsis, dehydration, DKA, blood loss
Maldisription.e.g. sepsis, anaphylaxis
Cardiogenis .e.g. arrythmia, heart failure
Neurogenic .e.g. spinal cord injury
Causes of Respiratory distress: Upper airway (stridor)
Croup Epiglottits Foreign Body Congenita Malformation Trauma
Causes of Respiratory distress: Lower airway (wheeze)
Asthma
Bronchiolitis
Pneumonia
Pneumothorax
Causes of unsconsciousness
Post-ictal Status epilepticus Infection .e.g. meningitis Metabolic .e.g. DKA< hypoglycaemia, electolyte disturbance, inborn error of metabolism Head Injury .e.g. trauma, NAI Drug/Poison Ingestion Intracranial Haemorrhage
Surgical emergency
Acute abdomen .e.g. appendicitis, peritonitis
Intestinal obstruction .e.g. intussusception, malrotation, bowel atresia/stenosis
Indicators of respiratory distress (Moderate)
Tachycardia RR >50 Nasal flaring Use of Accessory muscles Inter/subcostal recession Head retraction Unable to feed
Indicators of respiratory distress (Severe)
Cyanosis Tiring Reduced GCS Saturation <92% despite oxygen Rising pCO2
Indications for intubation
Severe respiratory distress Tiring due to work of breathing Progressive hypoxaemia Reduced consciousness level Progressive muscle weakness
Supportive therapy in respiratory failure
Oxygen SpO2 <92% (Max conc 0.60)
Noninvasive ventilation (CPAP and BPAP)
Invasive ventilatory support
Airway positioning
Infants: neutral position, avoid overextension
Children: sniffing position + jaw thrust
Chest compression positioning
Infant: 2 thumbs on lower sternum, hands round thorax
Small child: heel of hand, lower half of sternum
Large child: hands lower half of sternum
Endotracheal tube sizing
Internal diameter(mm) = (age/4) + 4
Length oral tube (cm) = (age/2) + 12
Length nasal tube (cm) = (age/2) + 15
Placement of intraosseous access
18 gauge trochlar with needle
Anterior surface
2-3cm below tibial tuberosity
Reversible causes of cardiac arrest
Hypoxia Hypovolaemia Hypo/hyperkalaemia Hypothermia Tension pneumothorax Thrombosis Cardiac tamponade Toxic/therapeutic disturbance
Factors in childhood dehydration
Unable to take oral fluids
Additional losses .e.g. diarrhoea, fever, tachypnoea
Loss of retaining mechanism .e.g. burns, urinary
Presentation shock (Early)
Tachypneoa Tachycardia Decreased skin turgor Sunken eyes and fontanelle Delayed cap refil >2s Mottled, pale and cold skin Cold-peripheral temp gap >4'c Decreased urinary output
Presentation Shock (Late)
Acidotic (Kussmal breathing) Bradycardia Confusion Depressed cerebral state Blue peripheries Absent urine output Hypotension
Initial fluid resuscitation
0.9% saline 20ml/Kg
Repeat twice if no response
Maintenance Fluid Requirments
First 10Kg 100ml/kg/24h
Second 10Kg 50ml/Kg/24h
Subsequent Kg 20ml/Kg/24h
Clinical features Sepsis
Fever Poor feeding Miserable, irritabilit, lethargic History of focal infection Tachycardia Tachypnoea Low BP Pupuric rash Shock Multi-organ failure
Common Organisms Spesis
Coagulase negative Staph
Gram negative N.meningitidis/E.coli
HiB, meningococcus and pneumococcus non-immunised
Neonates: Group B strep and E.coli
Mx Sepsis
Antibiotics Fluids Circulatory support: ionotropic FFP , cryoprecipitate and platelet transfusion in DIC Transfer to ICU
Mx anaphylaxis
ABCDE IM Adrenaline High flow Oxygen IV fluids Chlorpheniramine Hydrocortisone Salbutamol
IM Adrenaline Doses (1:1000)
> 12y 500mcg
6-12y 300mcg
<6y 150mcg
IV Chlorphenamine Dose
> 12y 10mg
6-12y 5mg
6m-6y 2.5mg
<6m 250mcg/Kg
IV Hydrocortisone Dose
> 12y 200mg
6-12y 100mg
6m-6y 50mg
<6m 25mg
Mx Status Epilepticus
ABCDE
High flow O2
Blood Glucose
5m Lorazepam
15m Lorazepam
25m Anaesthetic help, rectal paraldehyde, phenytoin over 20m/phenobarbitone over 5m
45m rapid sequence induction anaesthesia with thiopental
Neuroprtective strategies to prevent 2’ brain injury
Midline head positioning Tilt head 20-30' Fluid restriction with isotonic fluids Intubation and ventilation GCS<9 Maintain normocapnia (4.5-5.3kPa) Osmotic diuretics .e.g. mannitol Maintain high/normal BP Maintain normothermia Avoid hypotension/hypoxaemia
GCS Older children/Teens Eyes
4 opens spontaneously
3 sound
2 pressure
1 none
GCS Older children/Teens Verbal
5 Orientated 4 Confused 3 Words 2 Sounds 1 None
GCS Older children/Teens Motor
6 Obeys commands 5 Localising 4 Normal flexion 3 Abnormal flexion 2 Extension 1 None
GCS Children <4 Eyes
4 opens spontaneously
3 sound
2 pressure
1 none
GCS Children <4 Verbal
5 Talks normall/interacts 4 Words 3 Vocal sounds 2 Cries 1 None
GCS Children <4 Motor
6 Obeys commands
5 Localising
4 Normal flexion
3 Abnormal flexion (decorticate posturing)
2 Abnormal Extension (decerebrate posturing)
1 None
Pupillary signs in coma
Pinpoint fixed: opiates, barbituates, pontine lesion
Fixed, dilated: severe hypoxia, during/post-siezure, anticholinergics, hypothermia
Unilateral dilated: expanded ipsilateral lesion, tentorial herniation, 3rd nerve lesion, seizures
Features of apparent life threatening event
Cyanosis or pallor Absent, decreased or irregular breathing Change in tone No concerning features or detailed history Normal examination
Mx Apparent life threatening event
Period of observation ECG Perinasal swab for pertussis Brief monitoring with continuous pulse oximetry Reassurance of parents Parental training in BLS
Likely underlying disorder of apparent life threatening event
Age <60d Gestation at birth <32w Duration >1m Repeat event CPR given by trained medical professional Concerning feature of history Abnormality on examination
Risk factors for SIDS
Age 1-6m (Peak 2-4m) Low birth weight and preterm Male Illness in last 24h Lying prone (Main risk factor) Co-sleeping Overheating Infant pillow use Infant swaddling Low family income No maternal education Poor/overcrowded housing Maternal age <21y High maternal parity Maternal smoking in pregnancy/post-natally Maternal alcohol or drug use
Prevention of SIDs
Sleeping on back
Avoiding heavy wrapping and high room temp
Head uncovered
Blanket height max to shoulders
Feet to foot of cot
No smoking
Urgent medical advice for unwell infant
Baby in bedroom for first 6m
Avoiding baby in bed esp. with alcohol or drugs
Breastfeeding
Avoid sleeping with infant on sofa/armchair
dDx Encephalopathy
Infection Status epilepticus Trauma Intracranial tumour/haemorrhage/infarct/abscess Diaetes mellitus Hypoglycaemia Inborn error of metabolism Hepatic Failure Acute renal failure Poisoning Shock Hypertension Respiratory failure
Ix Meningitis
FBC
Culture: blood, urine, infective sites, CSF
Acute phase reactants
Rapid bacterial antigen/PCR
Features meningitis
Fever Irritability, lethargy, drowsiness Poor feeding/vomiting Rash Seizures Neck stiffness and pain Bulging fontanelle Overseas travel
Features status epilepticus
Hx of seizures Neurocutanrous lesions on the skin Developmental delay Ongoing seizure activity Focal neurology
Ix Status epileptics
Blood Glucose Electrolys: Na+, K+, Ca+, Mg+ Drug levels (esp. anticonvulsants) EEG CT scan
Ix Trauma
Radiology
Consider NAI work up
Features Trauma
Hx accident Bruising/haemorrhage Fractures .e.g. cervical spine Focal neurology Retinal haemorrhages
Ix Intracranial lesion
Cranial CT/MRI
Coagulation screen
Ix Diabetes Mellitus/Hypoglycaemia
Blood Glucose
Plasma electrolytes
Urine glucose and ketones
Blood gas
Ix Inborn error of metabolism
Blood Glucose Blood gas Blood amonia, lactate Urine amino and organic acids Plasma amino acids
Features metabolism encephalitis
Hx loss of consciousness Sudden collapse Consanguinity Death/illness siblings Developmental delay Hepatomegaly
Ix Hepatic falilure
Abnormal LFTs
Prolonged prothrombin
Ix Acute Renal Failure
Abnormal creatinine
Ix Posioning
Toxicology screen
Plasma level paracetamol and salicylates
Ix Shock
FBC Cultures Urea Electrolytes Blood gas
Ix Hypertension
Left ventricular hypertrophy on ECG or echo
Creatinine and electrolytes
Fundoscopy
Ix Respiratory Failure
Chest Xray
Arterial blood gas- hypoxia, hypercarbia
