Emergencies Flashcards
How should near drowning be Mx?
- Pt in prone position when out of water
- Give 100% oxygen
- Suspect hypothermia
- CPR against hard surface
- Maintain c-spine immobilisation
What are the causal theories of sudden infant death syndrome?
Most common at 2-3m
Obstructive apnoea:
- inhalation of milk
- airway oedema
- passive smoking
Central apnoea:
- faulty CO2 drive
- prematurity
- brainstem gliosis
Others:
- long QT interval
- staph infection
- overheating
- increased vagal tone or Magnesium increase
- immature diaphragm
What are burns and scalds, how do they present and what is a DDx?
Burn = damage to the skin or other body parts caused by extreme heat, flame, contact with heated objects, or chemicals
Scald = burn with hot liquid or steam
S+S =
- superficial 1st = red without blisters
- partial thickness 2nd = red, yellow/white, blister
- full thickness 3rd = stiff, white/brown, no blanching
- 4th = black, charred
DDx = accidental injury, child abuse
Outline the aetiology of meningitis
0-3m = group B strep, e.coli, listeria
3m-6y = strep pneumonia, Neisseria meningitidis, H.influenza
6-60y = strep pneumonia, Neisseria meningitidis
> 60y = strep pneumonia, Neisseria meningitidis, listeria
Viral (2/3) = enterococcus, EBV, adenovirus, mumps
What are the signs and symptoms of meningitis?
Early:
- Headache
- Leg pains
- Cold hands/feet
- Abnormal skin colour
- Fever
Later:
- Meningism = stiff neck, photophobia
- Kernigs sign (pain + resistance on passive knee extension with hip fully flexed)
- Brudzinski’s sign = +ve when passive forward flexion of the neck causes involuntarily raising of knees or hips in flexion
- Decreased conscious level, coma
- Seizures
- Petechial rash - non-blanching
- Sepsis = slow cap refill, decreased BP, increased temp, increased pulse
- Bulging fontanelle
How would you investigate meningitis?
Bloods = FBC, U+Es, LTF, glucose, coag (on LP don’t want the pt to bleed), BM
Blood cultures, throat swabs, rectal swabs
LP (do not perform in RICP) = CSF for microscopy, biochem, culture, PCR
CT head
CXR
VBG
Ophthalmoscopy
How would you manage meningitis?
A-E assessment
Dexamethasone 4-10mg/6h IV = reduced RICP/inflam
Start Abx
- <3m = IV cefotaxime + oral amoxicillin
- 3m-50y = IV cefotaxime
- > 50y = IV cefotaxime + oral amoxicillin
Viral = 3w acyclovir
IV fluids
Isolate for 1st 24h
Careful monitoring
Household/close contacts = rifampicin or oral ciprofloxacin
What are the complications of meningitis?
Encephalitis
Residual paralysis/focal neurology
Hearing loss
Cerebral abscess
Sepsis - DIC
Death
Outline the immune mechanism of an allergic reaction
Allergen 1st exposure - TH2 response
Allergen 2nd response = IgE cross-linking BY ALLERGEN
= mast cell degranulation
= increased vascular permeability, vasodilation, bronchial constriction
Describe the manifestations of anaphylaxis
Systemic activation of mast cells =
CVS = hypotension, tachy, syncope
Skin = angioedema, urticaria
Resp = cough, wheeze, dyspnoea, bronchospasm, hypoxia, stridor
Digestive = N+V, abdo pain, diarrhoea
How is anaphylaxis managed?
A-E
Epipen = adrenaline = vasoconstriction
Remove the trigger if possible.
Oxygen, IV fluid 20 mL/kg
Following initial resuscitation:
- Give slow IM/IV chlorphenamine
- Give slow IM/IV hydrocortisone (especially in people with asthma)
- Consider neb salbutamol/ipratropium if the person is wheezy
What is status epilepticus, its causes and presentation?
Seizures lasting more than 5 minutes or more than 3 seizures in one hour
S+S = tonic-clonic, tonic, clonic or myoclonic seizures, LOC
Causes =
- Intake of substance accidental/intentional, meds
- Infection = bacterial meningitis, encephalitis (travel - malaria)
- Hypoglycaemia = DM (insulin over use, illness), new-borns, metabolic disorders
- Febrile convulsion (common 6m-6y, generalised tonic-clonic short, swift recovery, complex/atypical) - usually triggered by the initial rise in temp
SOL = AV malformation, bleed, hypotensive encephalopathy, tumour
- Electrolyte abnormalities = hypoCa, hyperNa, hypoNa, hypoMg, hypoGly (SAIDH, fluid loss, Ca metabolism)
- Epilepsy = not associated with fever, but at higher risk of seizure when ill
- Vascular = stroke (MRI, MR angiogram)
- Cerebral hypoxia = significant resp/cardio failure
- Hepatic encephalopathy, renal encephalopathy, metabolic encephalopathy (mitochondrial)
- Congenital brain abnormalities
- Jaundice - kernicterus
What is paediatric trauma/injury, how does it present and what is its DDx?
Traumatic injury that happens to an infant, child or adolescent
S+S = bleeding, wound, LOC, N+V, impaired movement, balance, and/or coordination, dizziness, fatigue, headache
DDx =
- Non-accidental injury (NAI) (infants)
- Falls (toddlers)
- RTAs and sports injuries (older, adolescents)
Mx = primary survey, initial resuscitation, secondary survey, emergency treatment, definitive care
What are the types of poisoning in children?
1 = accidental ingestion of poisonous substance
2 = deliberate ingestion (overdose) of a mentally destressed child needing help
3 = deliberate poisoning of children (type of child abuse), safeguarding
What are the S+S of overdose/poisoning?
- feeling and being sick
- diarrhoea
- stomach pain
- drowsiness, dizziness or weakness
- high temperature of 38C (100.4F) or above
- chills (shivering)
- loss of appetite
- headache
- irritability
- difficulty swallowing (dysphagia)
- breathing difficulties
- producing more saliva than normal
- skin rash
- blue lips and skin (cyanosis)
- burns around the nose or mouth
- double vision or blurred vision
- mental confusion
- seizures (fits)
- loss of consciousness
- coma, in severe cases
How should overdose/poisoning be assessed?
Hx - what, where, when, how much/estimate
Exam
A-E - ?time critical (LOC, hypotension, arrhythmias, hypothermia/hyperthermia)
Blood paracetamol levels
Outline the Mx of overdose/poisoning
Remove the source of chemical
Alcohol = oral glucose for hypoglycaemia
TCA = ECG monitoring, charcoal, sodium bicarb, benzo for fits
Iron = charcoal contraindicated, bowel irrigation, chelation
Paracetamol = IV/IM naloxone to reduce respiratory depression
What is paediatric pyrexia, its causes and how does it present?
An infant or child is considered to have a fever if their temperature is 38°C or higher
Causes = bacterial, viral infection, Kawasaki disease, malignancy
S+S = >38, seizures, sweating, chills and shivering, headache, muscle aches, loss of appetite, irritability, dehydration, general weakness.
How should paediatric pyrexia be Ix?
Hx = addition Sx, perinatal complications, immunisations, recent antipyretic/Abx, prematurity,
Assess using traffic light system = colour, activity, respiratory, hydration, red flags
Electronic/infrared thermometers
Outline the management for paediatric pyrexia
Oral fluids
Paracetamol
Ibuprofen
Abx
The majority of fever is caused by self-limiting viral infection
What is sepsis, its causes and presentation?
Sepsis is a dysregulated response to infection which may result in organ damage and death
Causes = N. meningitides (meningococcus), strep pneumoniae (pneumococcus), staph aureus, group A and B streptococcus, E. coli
S+S = fever, lethargy, N+V, headache, abdo pain
How should suspected sepsis be Ix?
Exam =
- shock (hypotension, tachycardia, tachypnoea, cool peripheries, confusion)
- non-blanching rash
- fever
- signs of = meningitis/encephalitis, pneumonia, UTI, abdo pain/distention
Ix =
- FBC, CRP, lactate, glucose, U+Es, blood culture and urine testing
- stool culture is diarrhoea
- urine output
- LP (before Abx if time)
Use traffic light system in febrile children
What is a DDx for sepsis?
Leukaemia
Aplastic anaemia
Malignancy = lymphoma
Autoimmune = juvenile idiopathic arthritis
Kawasaki disease (children with prolonged fever)
How should sepsis be Mx?
Sepsis 6
- Give high flow oxygen
- IV/IO access = b/c, glucose, lactate, FBC, U+Es
- IV/IO antibiotics = cefotaxime
- IV/IO fluid = if hypoBP/lactate <2, 20ml/kg (10ml/kg neonates)
- Monitor UO (with catheterisation if necessary)
- Consider inotropic support = dopamine, epinephrine
Ensure senior doctor attends
What are the causes of paediatric shock and how does it present?
Causes:
- Hypovolemic = blood loss, D+V, burns, DI
- Cardiogenic = arrhythmia, cardiomyopathies, congenital heart disease
- Distributive = anaphylaxis, neurologic injury (head injury, spinal shock), sepsis(meningococcal), drug-related
- Obstructive = acute cardiac tamponade, tension pneumothorax, massive pulmonary embolism
S+S = increased capillary refill, skin turgor, decreased skin temp, pulse characteristics, hyperdynamic precordium, decreased UO, altered level of consciousness, increased respiratory effort, rash, poor feeding
How should shock be Ix?
Glucose
Arterial (ABG) or venous blood gas (VBG) measurements
Serum lactate levels
FBC
Prothrombin (PT) and partial thromboplastin (PTT) times
Fibrinogen and D-dimer levels
Fluid culture = blood, urine, cerebrospinal fluid
CXR
BNP
Central venous pressure measurement
Outline the Mx of shock
Oral rehydration
Initial resuscitation =
- A-E
- Oxygen
- IV/IO fluid bolus 0.9% NaCl (20ml/kg, if not improving 40ml/kg)
Hypoglycaemia = IV dextrose 0.5-1 g/kg
Abx
No improvement = ITU, tracheal intubation, mechanical ventilation, invasive BP, vasopressors and cardiac inotropic agents, correct metabolic derangements, support liver/renal failure
What is a differential diagnosis of an unconscious child?
Choking Opiate ingestion Overdose of toxic substance Decreased level of consciousness due to neurological disorder/ head injury Hypoglycaemia
How should an unconscious child be assessed and managed?
Assess = AVPU
Shout for help –> open airway –> 5 rescue breaths –> (no signs of life, no pulse, HR <60) 15 chest compressions –> 2 rescue breath + 15 chest compressions –> call resus team
What can cause a child to suddenly collapse and how does it present?
Vasovagal syndrome (neurocardiogenic syncope)
Heart rhythm problem (arrhythmia)
Structural heart disease (muscle or valve defects)
Orthostatic hypotension
S+S = before faint: dizziness, lightheadedness, nausea, changes in vision, cold/damp skin
How should sudden collapse be Ix?
ECG
24h ECG
Tilt table test
ECHO
How is sudden collapse Mx?
Acute = After an episode of syncope, your child should lie down for 10-15m
Neurally mediated syncope (NMS), or vasovagal syncope, is the most common cause of syncope in young patients
NMS
- avoid dehydration, long periods of standing and irregular mealtimes
- persistent = beta-blocker or fludrocortisone
Long QT syndrome = beta-blocker
Outline encephalitis
Aetiology = inflam of the brain tissue by: HSV (most common), varicella, enteroviruses, post-infectious encephalopathy, HIV, subacute sclerosing panencephalitis, metabolic abnormality
S+S = fever, altered consciousness, seizures, behavioural changes (can be insidious)
Ix = CSF PCR, EEG, CT/MRI (may show focal changes)
Mx = high dose IV aciclovir 3w (HSV, until excluded)
Outline the Mx of status epilepticus
Acute = A-E (airway, oxygen, glucose), call for senior help
IV access - (if cant get consider rectal, buccal, IO)
- Bloods (FBC, CRP, clotting, U+Es)
- Cultures
- VBG
IV/IO lorazepam (1st line - quicker, less resp depression) after 10m repeat lorazepam (can only have 2 doses of benzo)
Phenytoin infusion over 20m (whilst waiting for the phenytoin to be prepared: can give rectal paraldehyde) even if the seizure has stopped continue entire dose
Transfer to ICU - anaesthetist involvement (trial IV midazolam, RSI: rapid sequence induction, intubate and muscle relaxant)
Sepsis = start sepsis 6 (cefotaxime, ceftriaxone) Meningitis = LP if can be performed quickly before Abx, if not then give Abx with no delay then LP later PICP = mannitol, furosemide
