Emergencies and Life Support in Paeds Flashcards
What emergencies should I definitely know about in paediatrics?
Anaphylaxis Encephalitis Meningitis Overdose Poisoning Pyrexia Sepsis Shock Status epilepticus Sudden collapse The unconscious child
A child presents to A&E.
On observation of their activity level you notice they are not smiling at toys or other children. Their parent tells you they haven’t been doing much recently, and need lots of prompting to stay awake.
How alarmed should you be?
Fairly - these are indicating intermediate risk of a serious acute ilness (aka amber S+S)
A parent brings their child into A&E with sudden onset stridor and angioedema around the eyes and lips.
What triggers should we look for in the history of this presentation?
- Foods such as peanuts, fish, eggs, and milk
- Insect stings/bites (**bees and wasps)
- Recent medications (abx)
- Exposure to latex
A parent brings their child into A&E with sudden onset stridor and angioedema around the eyes and lips.
We suspect anaphylaxis. Form a list of further differentials with exclusion criteria.
- Asthma attack - stridor rather than wheeze, angioedema not common to asthma.
- Scromboid fish poisoning - ask about fish in hx
- Herediary angioedema
- Panic attack - stridor over SoB and angioedema suggest not.
A parent brings their child into A&E with sudden onset stridor and angioedema around the eyes and lips.
We suspect anaphylaxis.
What is the pathophysiology of anaphylaxis?
Exposure to an allergen ->
Release of IgE antibodies which in turn cause mast cell release of inflammatroy mediators, including histamine.
Histamine -> vessel permeability increases -> angioedema, vasodilation, and bronchoconstriction.
What is the management of anaphylaxis?
DR ABCDE assessment - remove trigger, IV access, O2.
Administer IM adrenaline according to childs age.
May need repeated doses.
What is the dosing of adrenaline for children aged:
a) 1 month - 5 years
b) 6 - 11 years
c) 12 - 17 years
a) 150 micrograms
b) 300 micrograms
c) 500 micrograms
How frequently can we re-administer adrenaline?
Every 5 minutes according to obs (BP, HR, RR)
Other than IM adrenaline, what can we give for anaphylaxis management?
- Antihostamines (oral)
- Steroids (IV hydrocortisone)
What investigations can we do for suspected anaphylaxis?
When is this appropriate?
(Bloods) Mast cell tryptase up to 2 hours after onset of symptoms.
If anaphylaxis was suspected/difficult to diagnose clinically.
Do not delay treatment of suspected anaphylaxis to take bloods for this!!!!!
If a child doesn’t respond to IM adrenaline in anaphylaxis, what should we do?
Intubate quickly to avoid cricothyroidotomy.
Call for senior help!!
What is encephalitis?
Inflammation of the brain parenchyma usually due to viral infection.
A parent brings their child in to the GP because they have become clumsy and confused recently, and pyrexic.
What emergencies should we be considering?
Encephalitis Meningitis (symptoms of meningism?) Diabetic ketoacidosis/hypoglycaemia Drug overdose Hepatic encephalopathy
What are some of the common viruses that cause encephalitis?
HSV 1 and 2 (2 more common in neonates than adults) VZV EBV Measles Mumps Rubella Influenza CMV Adenoviruses
What signs can we look for to help determine the causative organism behind encephalitis?
- Cold sores -> HSV
- Parotid gland swelling -> mumps
Muuuuuch Less commonly:
- Mosquito bites w/ travel hx - Japanese B arbovirus and West Nile virus
- Hydrophobia, delusions, hallucnations, anxiety -> rabies.
How should we investigate suspected encephalitis?
- CT head -> shows cerebral oedema
- MRI head -> subtle inflammation
-Lumbar puncture if imaging excludes intracranial mass and RICP
What are the parenchymal signs of encephalitis?
- Seiures
- Confusion
- Dysphasia
- Cranial nerve palsies
- Ataxia
- Hemiparesis
What are the meningeal signs associated with meningitis and encephalitis?
- Headache
- Photophobia
- Neck stiffness
- Vomiting
- Positive Kernig’s sign
What is Kernig’s sign?
Positive sign is when the hip is flewed to 90 degrees but the leg is unable to straighten due to severe hamstring stiffness.
How should we manage encephalitis?
- If HSV suspected as cause, immediate IV aciclovir for 2-3 weeks
- Admit to ICU
- Dexamethasone for RICP
- Anticonvulsants if needed
What are the complications of encephalitis?
- 10-30% mortality (even with Rx)
- Long term cognitive impairment
- Epilepsy
What are the causes of meningism?
- Most are viral
- Some are bacterial
- Endogenous causes - malignancy, autoimmune disease, subarachnoid haemorrhage.
Which type of meningitis is generally more serious?
Bacterial - viral tends to be self-limiting, and bacterial disease can be more severe medically.
In an infant, what signs of meningitis do we need to look for?
-Irritability
-Tachycardia
-Kernig’s sign +ve
-Brudzinski’s sign
-Bulging fontanelle
-Stiff body
-Fever
-Poor feeding/vomiting
-Rash
-Signs of shock/sepsis
(-Neurological signs)
What is a positive Brudzinski’s sign?
Passive flexion of the neck -> flexion of the hip &/or knee.
Tell me about the rash associated with meningitis.
Actually due to meningococcal sepsis, not meningitis.
- Associated with bacterial meningitis
- Non-blanching
- Small red pinpricks which turn into red or purple blotches
What are the viral causes of meningitis?
- Echovirus
- Mumps (rare in UK)
- EBV/HSV/VZV
- Influenza
How is viral meningitis managed?
Once viral cause is established, symptomatic control.
Ibuprofen or calpol for fever.
What is the difference in mortality between meningitis presenting just with meningism, and meningitis presenting with sepsis?
Double the mortality if presenting with septicaemia.
In neonates, what are the causes of bacterial meningitis?
- E. coli
- Group B Strep
- Listeria
In 3 months to 6 years, what are the causes of bacterial meningitis?
- N. meningitidis
- Strep. pneumoniae
- H. influenzae
In a child over 6 years, what are the causes of bacterial meningitis?
- N. meningitidis
- Strep. pneumoniae
Which bacteria confers the worst prognosis for meningitis?
Meningococcus
What more unusual cause of meningitis do we need to look out for, especialy somewhere like Leicester?
TB
What is the pathophysiology of meningitis?
Infection of meninges -> host immune response where leukocytes release inflammatory mediators -> cerebral oedema -> RICP and decreased blood flow to brain.
How do we investigate suspected meningitis?
- Lumbar puncture
- BUT don’t delay starting treatment to wait for LP!
-Sepsis screen
What are the contraindications for a lumbar puncture in meningitis?
- RICP/Signs of RICP
- Focal neurological signs
- Cardioresp distress
- Coagulopathy/Thrombocytopaenia
What does bacterial meningitis look like on CSF test results?
- Increased white cells (1000-5000)
- Turbid in appearance
- Low glucose
- Normal or high protein
- Bacterial postive
What does viral meningitis look like on CSF test results?
- Increased white cells (10-2000)
- Colourless in appearance
- Normal glucose
- Normal or low protein
- Bacterial culture negative
A child presents to GP with meningism and signs of shock.
What can the GP do?
- Start broad spec abx immediately
- Send to A&E immediately
A child presents to A&E with meningism and signs of shock.
How do we manage it?
- ABCDE approach
- Start or continue IV broad spec abx
- Treat shock with IV fluids
- Dexamethasone (if older than neonate)
- Consider ventilation
What antibiotics do we tend to give for meningitis?
3rd gen cephalosporin (cefotaxime/cephalexin)
IM benzylpenicillin as an alternative
What complications of meningitis might a child develop?
- Hearing loss
- Vasculitis
- Cerebral infarct
- Subdural effusion
- Hydrocephalus
- Cerebral abscess
A mother brings in her 3yo son to A&E because she couldn’t rouse him from deep sleep.
Form a list of differentials.
- Overdose of a medication
- Poisoning
- Meningitis
- Respiratory depression secondary to acute resp/cvs events e.g. tension pneumothorax, cardiac tamponade, asthma, anaphylaxis, foreign body, pericarditis, arrhythmia.
A mother brings her child in as the child has a temperature of 40 degrees.
Form a list of differentials.
- Infection - viral, bacterial, or fungal. Look out for other symptoms and signs to diffferentiate simple infections from serious infections (e.g. URTI vs pneumonia)
- Dehydration
- Post-surgery
- Kawasaki’s disease
- Post-immunisation
- Neoplastic disease
- Factitious disease
A mother brings her child in as the child has a temperature of 40 degrees.
We suspect infection as the most likely cause. How should we find out what infection is causing it?
Take a detailed history of each system, including about urinary symptoms, joint pain, recent conditions or treatments.
Examine:
- Ears (e.g. for otitis media)
- Throat (e.g. for tonsilitis/quinsy)
- Respiratory system
- Neuro system (meningitis)
- Skin for rash
- Heart (more chronic fever)
- GI (IBD)
Investigate:
- Urine culture
- Nose/throat swabs
- ?sputum culture if possible (older children)
- CXR if appropriate
The paramedics bring in an unconscious child after the mother found him like that.
What is the initial management?
ABCDE assessment
The paramedics bring in an unconscious child after the mother found him like that.
In the absence of a history, what possible causes could we find on initial assessment?
Airway - anaphylaxis, foreign body
Breathing - asthma, LRTI, ARDS, hypoxia, CO poisoning
Circulation - shock, arrhythmia, cardiomyopathy, myocarditis, SIADH
Disability - Hypoglycaemia/DKA, electrolyte disturbance
Exposure/Everything else - RICP (meningitis), head trauma, CNS/spinal trauma, overdose (e.g. opiate), seizure
What general things can we look for on examination of an unconscious child to find out the cause of LoC?
- Vital signs (see abcde)
- Medic alert bracelet (diabetic, allergies, other LTCs)
- Skin - trauma, rash, jaundice, needle tracks
- Breath - odours of alcohol, etones, hydrocarbons, or toxins.
The paramedics bring in an unconscious child after the mother found him like that.
You think the eyes may be the window to the diagnosis (for some reason) - what can you look for?
- Pupil size
- Pupil reactivity
- Bilateral comparison of pupils
- Fundoscopy - retinal haemorrhages and papilloedema
What, in general, are the signs of RICP?
- Abnormal espiratory pattern
- Unequal or unreactive pupils
- Systemic HTN, bradycardia
- Tense fontanelle
- Abnormal posture or muscle flaccidity
The paramedics bring in an unconscious child after the mother found him like that.
To help narrow down your differentials, what investigations can we do?
- Bloods -> FBC, clotting profile. Glucose, U&Es, LFTs, ammonia, lactate.
- Toxicology - urine, blood, gastric aspirate. Serum lead
- ABG for acid-base
- Micro- blood and urine cultures
- Cranial CT or MRI
An infant is choking on something.
Describe what you would do.
(Check airway by pressing the chin down to look in the mouth)
Lie the infant facedown on your arm with their head supported by your hand (keep the airway open by keeping head in neutral position) and tilt them downwards so graviy can help.
Perform 5 back-slaps, being careful to avoid hitting the head.
Swap the child over to lying on their back on your arm keeping them tilted head down.
Perform chest compressions at the level of the nipples with 2 fingers.
Repeat until dislodged, or until 3 cycles have been done. Do not tip the baby back up as they will swallow the object. Try to remove from mouth without putting fingers in the mouth.
If 3 cycles have been done, start ABC.
A mother in a panic brings her infant, and is terrified she has died.
Describe what you would do.
- Call for help!!
- Shake and call name for any response
- Look in airway for sign of bockage. Assess airway, and any noises being made.
- Count the breaths in 4 seconds - should breath about 4 times in 10 seconds.
- If not breathing, do 5 RESCUE BREATHS.
- Recheck for signs of life (brachial/femoral pulse)
- Start chest compressions - 2 fingers on chest in siggital plane. Do 15 chest compressions, then 2 breaths. Repeat until help arrived or infant recovers.
What kinds of shock might a child be in?
- Hypovolaemic
- Maldistribution of fluids
- Cardiogenic
- Neurogenic
What are the common causes of hypovolaemic shock in children?
- Sepsis
- Dehydration (2ary to e.g. gastroenteritis)
- DKA
- Blood loss
What are the common causes of shock caused by maldistribution of fluids in children?
- Sepsis
- Anaphylaxis
What are the common causes of cardiogenic shock in children?
- Heart failure
- Arrythmias
What are the common causes of neurogenic shock in children?
Spinal cord injury
How does the body compensate in the early stages of shock?
- Increasing HR and resp rate
- Diverting blood flow from the peripheries
- Redistribute venous reserve volume
What is the management priority when a child presents in shock?
Fluid resuscitation
What are the rules for fluid resus in children?
0.9% saline or blood (depending on mechanism of shock)
20ml/kg
Reassess and repeat x2 if necessary
How do you calculate maintenance fluids in children?
100ml/kg/24 hours for 1st 10kg of weight.
Additional 50ml/kg/24 hours for 2nd 10kg of weight.
20ml/kg for subsequent kgs past 20kg.
How much maintenance fluids would a 34 kg child need? At what rate?
Show your workings.
(100x10) + (50x10) + (14x20) = 1780ml/day
= 74.2 ml/hour
A child is in shock due to gastroenteritis.
You need to give fluids but notice that on her bloods, she is hypernatraemic.
Why is this relevant?
Resus fluids need to be given over 48 hours instead of 24 hours.
This helps prevent cerebral oedema.
In hypernatraemic dehydration, what rate do we want to reduce Na by?
0.5mmol/L per hour
How might hypernatraemic deydration present differently to normal dehydration?
Jittery movements Hypertonia Hyper-reflexia Convulsions Drowsiness/coma
Tell me some details about Sudden infant death syndrome.
aka SUDI
Risk factors - baby sleeping prone, parental smoking, prematurity, bed sharing, and hyperthermia.
Following a cot death, what things can we do to protect siblings?
- Educate parents
- Screen for sepsis and inborn errors of metabolism
- CONI scheme (care of next infant)
In who is a temperature over 38 degrees a serious sign?
Anyone under age 3 months - they are at high risk of serious illness.
A child with known epilepsy is brought into A and E, having been seizing for half an hour.
What do you want to ask?
You don’t really, not until later. This is status epilepticus so it’s an emergency, and the seizure needs to be terminated.
Could ask if parents have tried anything, if there has been any recovery, any other events e.g. vomiting, head trauma.
A child with known epilepsy is brought into A and E, having been seizing for 5 minutes with no recovery.
What are we worried about? What is first-line treatment?
Status epilepticus.
Benzodiazepines such as diazepam or lorazepam.
A child with known epilepsy is brought into A and E, having been seizing for 10 minutes without recovery. There was no response to benzos.
What is second-line treatment?
Other AEDs:
- Phenytoin
- Midazolam
- Pentobarbital
- Sodium valproate
A child with known epilepsy is brought into A and E, having been seizing for half an hour. Other drugs have failed to terminate the seizure.
What can we use now to achieve rapid seizure control?
General anaesthesia
A child with known epilepsy is brought into A and E, having been seizing for half an hour.
What should have been done as soon as possible?
ABCDE assessment with airway protection and establishing IV access.
What are the neurological complications of status epilepticus?
- Primary brain injury (excitotoxic neuronal injury)
- Secondary brain injury (hypoxic, hypoperfusion, hypertension)
- Intracellular hypercalcaemia
What are the possible respiratory complications of status epilepticus?
- Hypoxia
- Aspiration (-> pneumonitis)
- Respiratory acidosis
What are the possible cardiac complications of status epilepticus?
- Arrhythmias
- Tachycarida
- Hypotension
What are the possible metabolic/renal complications of status epilepticus?
- Hypoglycaemia
- Hyperglycaemia
- Lactic acidosis
-Rhabdomyolysis
Which benzo given by which route is considered best for managing status epilepticus?
IV Lorazepam
What general anaesthetic agents can we use in treatment resistant status epilepticus?
Propofol and suxamethonium
What guidelines look at pyrexia in children?
The NICE fever in under 5s guidelines
What basic obs should always be recorded in a febrile child?
Temperature, cap refill, heart rate, and resp rate.
How should temperature be recorded in a febrile child?
Electronic thermometer in axilla if under 4 weeks, or electronic/chemical dot or infra-red tympanic thermometer
A child present with a fever and some amber flags. What can you do?
Safety net or refer for specialist paediatric assessment
A child presents with a fever and red flags. What should you do?
Refer urgently to a paediatric specialist.
What is the priority with a febrile child?
ABCDE assessment to find the cause of fever for definitive treatment.
A 2 month old infant is brought in with a history of gastroenteritis and being difficult to rouse. O/E they are cold and mottled.
What do you want to do?
ABCDE assessment and start Paediatric Sepsis 6.
Who needs to be notified if a child is septic?
A senior doctor (senior ST or consultant)
What are the paediatric Sepsis 6?
Give high flow O2
Obtain IV access and take blood for culture, glucose, lactate, FBC, U&Es, coag, CRP, and do LP (unless contraindicated)
Give IV/IO antibiotics
Fluid resus if appropriate
Escalate
Consider inotropic support early (e.g. adrenaline)
What do we give for sepsis in an 1-3 month old, and why?
3rd gen cephalosporin e.g cefrtriaxone
AND
Amoxicillin to cover for Listeria
What do we give for sepsis in an infant under 1 month old?
Gentamicin
Amoxicillin
Cefotaxime
What do we give for sepsis in a child over 3 months old?
Ceftriaxone
When would we give different agents for sepsis?
If sepsis was occuring in a haematology/oncology patient
A child has sepsis and is started on ceftriaxone. Meningitis is confirmed. What do we do to the abx regime?
Keep it the same as ceftriaxone can cross the BBB so works for meningitis :)
