Emergencies Flashcards
Common causes of anaphylaxis?
Food is most common - nuts
Drugs
Venom - wasp sting
What is the acute management of anaphylaxis? What dose is given for each age group?
Adrenaline 1:1000 - <6 months - 150mcg 6m - 6y - 150mcg 6 - 12 years - 300mcg >12 years - 500mcg
Hydrocortisone - <6 months - 25mg 6m - 6y - 50mg 6 - 12 years - 100mg >12 years - 200mg
Chlorphenamine - <6 months - 250mcg/kg 6m - 6y - 2.5 mg 6 - 12 years - 5mg >12 years - 10mg
What and where is the best way to administer adrenaline in anaphylaxis?
Anterolateral aspect of middle third of thigh.
Repeat every 5 minutes
IM
Management of anaphylaxis following stabilisation of patient?
Observe for 6-12 hours from onset of symptoms - biphasic reactions can occur in 20%.
Serum tryptase levels taken if unsure if it was true anaphylaxis - remains elevated for 12 hours following anaphylaxis.
Symptoms and signs of meningitis?
Headache, fever, nausea, vomiting, photophobia, drowsiness, seizures.
Neck stiffness, purpuric rash.
Kernig’s sign - severe stiffness of hamstrings causes inability to straighten leg when hips flexed to 90 degrees.
Brudzinski signs:
Cheek - pressure on cheek elicits reflex rise and flexion on forearm.
Symphysial sign - pressure on pubic symphysis elicits reflex flexion of hip and knee and abduction of leg.
Neck sign - forced flexion of neck elicits reflex flexion of hips.
Causes of meningitis in different age groups?
Neonates to 3 months - Group B strep, E. coli, listeria monocytogenes.
1 month to 6 years - Neisseria meningitis, strep pneumonia, H. influenza
> 6 years - neisseria meningitidis, strep pneumonia.
Investigations of meningitis?
Lumbar puncture for CSF analysis.
Contraindication for lumbar puncture?
Focal neurological signs Papillioedema Significant bulging of fontanelle DIC Signs of cerebral herniation Meningococcal septicaemia.
CSF results for bacterial, viral and TB cases?
Bacterial - cloudy, low glucose, high protein, 10-5,000 polymorphs
Viral - clear/cloudy, 60-80% of plasma glucose, normal or raised protein, 15-1,000 lymphocytes.
Tuberculosis - slightly cloudy, fibrin web, low glucose, high protein, 10-1,000 lymphocytes.
Management of meningitis?
<3 months - IV amoxicillin + IV cefotaxime
>3 months - IV cefotaxime
Aciclovir if viral cause
Steroids - If >1 month and H.influenza then give dexamethasone
Fluids to treat shock
Cerebral monitoring
Public health notification and abx prophylaxis for contacts.
What abx prophylaxis do you give for contacts of meningitis patient?
Ciprofloxacin or rifampicin.
What vaccinations are available for meningitis?
Routine Men B - 2 months, 4 months, 12-13 months.
Men ACWY - 14 years and then 17-18 years.
Also offered to patients with asplenia, splenic dysfunction or complement disorder.
Causes of encephalitis? Where does it most commonly affect?
Temporal and inferior frontal lobes. Usually due to HSV-1 Bacterial - lyme disease, TB, syphilis Parasites (toxoplasmosis) Autoimmune reactions
Symptoms of encephalitis?
Fever, headache, bulging of fontanelles, photophobia, neck stiffness, sleepiness, lethargy, increased irritability, seizures, skin rash, trouble talking, confusion or hallucinations, loss of appetite, unsteady walking, N+V.
How to diagnose encephalitis?
MRI head +/- contrast or CT head. (MRI is better)
Blood tests for ab’s or infection
Urine and stool tests
Sputum culture
EEG
LP unless contraindicated - lymphocytosis and high proteins seen.
Management of encephalitis?
ICU admission and rapid treatment
Aciclovir (antiviral) - IV TDS for 14-21 days.
Autoimmune cause - corticosteroids, IVIG, plasma exchange.
Treat complications - anticonvulsants, NG tube, fluids
Complications of encephalitis?
Memory problems, speech/language problems, personality changes, epilepsy, emotional/psychological problems, problems with balance/co-ordination, problems with attention/concentration.
Causes of overdose and poisoning?
Accidental ingestion - most common in young children
In adolescents - deliberate self-harm
Non-accidental poisoning by care giver
Inadvertent poisoning by doctors.
What would you examine for poisoning?
Inspect oropharynx and vomitus. Assess GCS/AVPU Small pupils - opiates, barbiturates Tachypnoea - salicylate poisoning Cardiac arrhythmias - tricyclic antidepressants or digoxin.
Diagnosis of poisoning?
Bloods - measure specific levels of poison
Urine specimen for analysis
Blood gas, LFTs, coagulation studies.
How to manage poisoning generally?
Activated charcoal - 1g/kg NG/PO. Within 1 hour of ingestion.
Management of deliberate overdose?
Admit to hospital and speak to someone alone.
Paediatric trained psychologist/psychiatrist should assess them, and appropriate follow-up should be planned prior to discharge.
Adverse effects of iron poisoning and treatment?
Shock, gut haemorrage
IV desferrioxamine
Adverse effects of paracetamol poisoning and treatment?
Liver failure
IV N-acetylcysteine
Adverse effects of alcohol and treatment?
Severe hypoglycaemia
10% IV dextrose
Adverse effects of salicylates and treatment?
Metabolic acidosis
Gastric lavage if <4 hours, activated charcoal, bicarb to alkalinise urine.
Adverse effects of antifreeze and treatment?
Widespread cellular damage.
Ethanol or dialysis if severe
Adverse effects of tricyclic antidepressants and treatment?
Cardiac dysrrhythmias
Sodium bicarbonate
Adverse effects of opiates and treatment?
Respiratory depression
Naloxone
Adverse effects of ecstasy and treatment?
Hyperpyrexia, rhabdomyolysis, dysrhythmias
Active cooling, benzodiazepines for anxiety.
Red flags for sepsis?
Appears ill, looks mottled, cyanosis, non-blanching rash.
Breathing - grunting, apnoea, reduced sats, increased RR
Circulation - tachycardia, hypotension, not passing urine
Demeanour - no response to social cues, does not wake, continuous cry.
Exposure - temp <36 or >38 in <1 months olds.
Sepsis 6 in paediatrics?
High flow oxygen
Blood tests (IV or IO) - cultures, gases, FBC, CRP, coagulation, U&Es, LP
IV broad spec abx within an hour -
Early onset neonatal sepsis - benzylpenicillin and gentamicin.
Late onset neonatal sepsis - ampicillin and gentamicin.
Infants and young adults - cefotaxime for CAP and tazobactam or meropenem for HAP.
Fluid resuscitation - If lactate >2 give 20ml/kg of normal saline over 5-10 minutes.
Be aware of overload.
Escalation - review by senior clinician
Discuss with paediatric consultant and PICU if lactate >4 or no clinical improvement following second fluid bolus.
Inotropic support if physiological parameters aren’t restored after 40ml/kg fluids - IV adrenaline or dopamine may be given - ask PICU for help.
Causes of shock?
Hypovolaemic - most common in paediatrics due to diarrhoea and vomiting
Distributive shock - sepsis, anaphylaxis, DKA
Cardiogenic shock - arrhythmias, heart failure.
Features of shock?
Cold and clammy peripheries Pale and mottled skin Tachycardia with reduced pulse volume Capillary refill >3 secs Late signs - acidotic breathing, agitation and confusion, oliguria, hypotension.
3 phases of shock?
Compensated - vital organ function preserved
Uncompensated
Irreversible - retrospective diagnosis.
Management of shock?
High flow oxygen Airway protection Continuous monitoring of respiratory rate, oxygen sats, heart rate, BP IV access Fluid resuscitation Reassess after each bolus Consider intubation if signs of fluid overload or reduced GCS. Consider inotropes if BP not increasing.
Common causes of cardiorespiratory arrest?
Resp - upper airway obstruction, respiratory failure, smoke inhalation from fire.
CVS - arrhythmia, heart failure, myocarditis.
Neuro - cerebral oedema, head injury, birth asphyxia, brainstem injury.
Severe hypoxic insult (suffocation, drowning).
Trauma - RTA, fall, NAI
Management of sudden collapse?
Call for help Open airway Check for respiration Five rescue breaths using high flow oxygen via bag and mask Check for signs of life External cardiac massage CPR at 15:2 compressions to breaths IV or IO access Give adrenaline Check cardiac rhythm and defib if appropriate. Check blood sugar.
Management of choking?
Ineffective cough -
Unconscious - open airway, 5 breaths, start CPR
Conscious - 5 back blows, 5 abdominal/chest thrusts
Effective cough -
Encourage cough, check for deterioration until obstruction relieved.
Causes of unconscious child?
Infection - meningitis, encephalitis Trauma - head injury Metabolic - hypoglycaemia Primary CNS disorder - seizures (eg epilepsy) Drugs - opiates, lead
What are the features of different depths of burns?
Superficial burn - red, no blisters, affects epithelial layer
Partial thickness burn - pink or mottled, blisters, some dermal damage.
Full thickness burn - painless, white/charred, full dermal and nerve damage.
Management of burns
Run cold water over affected part for 20 minutes.
A-E
Adequate analgesia - entoanox, intranasal diamorphine or IV morphine in older children.
Fluid resuscitation
Replacement IV fluids - % burns x weight (kg) x 3 over 24 hours.
Wound care - sterile dressings or cling film, minimal handling.
Transfer to local tertiary burns unit in the following:
- partial thickness burns >2% (>3% in adults)
- full thickness burns >1%
Inhalation injury (CO inhalation)
- burns to difficult areas (face, neck, hands, feet, perineum)
- burns over joints
Electrical or chemical burns
- Suspicions of non-accidental injury
- Circumferential burns to trunk/limbs
- Burns associated with major trauma/significant comorbidities.
When to consider non-accidental injury with burns or scalds?
Glove and stocking distribution (immersion injury).
Delay in presentation.
Burns or scalds to buttocks or perineum.
Other social concerns in family.
Clinical features of head injury?
Haematoma, laceration, depressed fracture, anterior fontanelle torsion, blood or CSF leak from ears or nose.
CNS signs - reduced GCS/AVPU, check fundi and pupillary reflexes, examine for focal neurological signs.
Investigations of head injury?
CT head
Skull X-ray
Causes of primary and secondary brain damage in head injury?
Primary - cerebral laceration and contusion, diffuse axonal injury, dural sac tears, intracranial haemorrhage.
Secondary - ischaemia from shock/hypoxia/increased ICP, hypoglycaemia, CNS infection, seizures, hyperthermia.
Features of expanding haematoma?
Reduced consciousness
Focal neurological signs
Depressed skull fracture
Cushing triad - bradycardia, increased systolic BP, irregular respirations.
Major risk factors for sudden infant death syndrome?
Putting baby to sleep prone Parental smoking - risk increases 5 fold Prematurity Bed sharing Hyperthermia - over-wrapping or head covering.
Others - male, multiple births, social classes 4 and 5, maternal drug use, winter.
What are the protective factors for sudden infant death syndrome?
Breastfeeding
Room sharing - but not bed sharing
Use of dummies (pacifiers)
