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Y4 Paediatrics > Emergency > Flashcards

Emergency Flashcards

1
Q

what is the pathophysiology of croup?

A
  • acute infective URTI affecting young children aged 6m-2yrs
  • causes oedema in larynx - mucosal inflammation between nose and trachea
  • parainfluenza virus, other influenza, adenovirus
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2
Q

what are the key points in a history for croup?

A
  • 1 to 4 day history of non-specific cough, rhinorrhoea, fever
  • barking cough, clusters
  • increased work of breathing
  • sx worse at night
  • fever low grade
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3
Q

what are some examination findings for croup?

A
  • stridor
  • high pitched wheeze
  • or chest may sound normal
  • resp distress signs
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4
Q

what are some complications for croup?

A

complications - lymphadenitis, otitis media, dehydration, rarely bacterial superinfection and very rarely pulmonary oedema and pneumothorax

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5
Q

what are some differentials for croup?

A

epiglottitis
inhaled foreign body
inhaled noxious substance
acute anaphylaxis
diphtheria
peritonsilar abscess
vocal cord paralysis

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6
Q

what are the initial investigations for croup?

A
  • normally clinical decision - consider distress caused to child when considering additional tests
  • FBC, CRP, U&E
  • CXR - to identify other causes like foreign bodies
  • direct or indirect laryngoscopy not performed unless atypical or other cause suspected
  • pulse oximetry
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7
Q

how is croup managed?

A

home managed
- single dose of oral dexamethasone
- resolves within 48h but may last for a week
- viral so no abx
- supportive
admission if severe resp distress for nebulised budesonide, IV adrenaline and keep child calm

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8
Q

when would you consider admission in croup?

A
  • consider admission if previous history of severe obstruction, <6m, immunocompromised, inadequate fluids, diagnosis uncertain
  • immediate hospital admission if other disorder suspected like quinsy, laryngeal diphtheria, foreign body etc
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9
Q

what is the pathophysiology of dehydration?

A
  • inadequate fluid intake
  • excessive fluid loss
    *infants and children are at greater risk of developing as higher metabolic rates, inability to communicate thirst or self-hydrate effectively and greater water requirements per unit weight
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10
Q

what are some key points in history of dehydration?

A
  • recent ongoing fluid loss like D+V
  • quantity of fluid loss
  • E+D
  • urinary hx
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11
Q

how might mild dehydration present on examination?

A
  • mild: dry mucous membranes, thirsty child, cool peripheries, decreased urine output
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12
Q

how might moderate dehydration present on examination?

A
  • moderate: dry mucous membranes, cold peripheries, oliguria, reduced skin turgor, sunken eyes, sunken fontanelle, high HR, raised CRT, irritable, lethargic
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13
Q

how might severe dehydration present on examination?

A
  • severe: moderate + weak, thready pulse, anuria, reduced consciousness, raised RR, shock
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14
Q

what are some red flags on examination for dehydration?

A
  • Appears unwell or deteriorating
  • Altered responsiveness
  • Sunken eyes
  • Reduced skin turgor
  • Tachycardia
  • Tachypnoea

*hypernatraemic dehydration

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15
Q

how might hypernatraemic dehydration present?

A

more water than sodium lost from body

  • Jittery movements
  • Increased muscle tone
  • Hyperreflexia
  • Convulsions
  • Drowsiness or coma
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16
Q

how is dehydration managed?

A
  • oral hydration solution
  • IVF given
  • manage fluids after rehydration
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17
Q

what is a febrile convulsion?

A

A seizure associated with a febrile illness not caused by an infection of the central nervous system, without previous neonatal seizures or a previous unprovoked seizure and not meeting the criteria for other acute symptomatic seizure, which occurs in children aged 6 months to 6 years

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18
Q

how might febrile convulsions present?

A
  • fever 38c<
  • age 6m to 6y
  • tonic clonic seizure usually on first day of fever
  • infection related
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19
Q

what are some important questions to ask regarding febrile convulsions?

A
  • has child been vaccinated?
  • are they at school?
  • previous treatment with Abx?
  • any history of trauma or toxin ingestion?
  • FHx?
  • developmental history
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20
Q

what are some red flags regarding febrile convulsions?

A
  • meningism
  • complex seizures
  • febrile status epilepticus
  • CNS infections

*complications recurrence

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21
Q

what are some risk factors for febrile convulsions?

A

age of onset less than 18m
shorter durations
low grade fever with seizure (<40c)
multiple in same episode
day nursery attendance
FHx

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22
Q

what are some investigations done for febrile convulsions?

A
  • general observations - temp, HR, RR, SATS, mental status
  • if source of infection unknown and child under 1 year old,
    • urinalysis
    • bloods - FBC, CRP, U&E, calcium, glucose, Mg, blood cultures
    • stool cultures
    • LP
    • imaging - CXR
    • CT, MRI, EEG not generally done in simple but consider in complex cases
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23
Q

how is a febrile convulsion managed?

A

*Short febrile seizures of less than 5 minutesdo notneed any specific treatment

  • A-E
  • keep hydrated
  • paracetamol doesn’t stop recurrence
  • first presentation of simple admitted, often sent home on same day after observation unless less than 18m old, no obvious source of infection or parental anxiety high or request
  • recurrent febrile convulsions occur thenbenzodiazepine rescue medicationmay be considered
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24
Q

how is DKA characterised?

A

acidosis - pH below 7.3 or bicarb <15
ketonaemia - blood ketones above 3
blood glucose over 11

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25
Q

what is the pathophysiology of DKA?

A

absolute insulin deficit caused by autoimmune destruction of pancreatic beta cells means ‘starvation midst of plenty’ where body cannot utilise the glucose for metabolism

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26
Q

what does DKA cause?

A
  • this insulin deficit leads to a rise in glucagon, cortisol, growth hormones etc which stimulates lipolysis resulting in rise of acidic ketone bodies
  • hyperglycaemia and the glycosuria leads to osmotic diuresis and dehydration due to polyuria
  • cerebral oedema risk!
27
Q

what are some RF for DKA?

A

most new patients present like this to A&E
non-compliance with meds
device failure
changing insulin requirements during puberty
increased ingestion of glucose
infection

28
Q

how might DKA present?

A
  • generally unwell
  • lethargy
  • N+V
  • abdo pain
  • sx of shock etc
29
Q

How is DKA investigated?

A
  • bedside blood glucose and ketones - urine ketones diagnose
  • blood gas for acidosis
  • lab samples for blood glucose, U&E, FBC, creatinine
  • 12 lead ECG for hypokalaemia
  • other autoimmune screening
30
Q

how is DKA managed?

A
  • A to E
  • not clinically dehydrated and not vomiting treat DKA with oral fluids and subcutaneous insulin
  • 0.05 – 0.1 units/kg/hour of a soluble insulin
  • IVF replacement then addition of insulin infusion
  • stabilisation and continues care - one to one nursing, repeated blood glucose, ketones, blood gas, U&Es
31
Q

what is the pathophysiology of hypoglycaemia?

A
  • transient neonatal hypoglycaemia
  • in those with DM missed meal, excessive dosing, alcohol ingestion, exercise
32
Q

how does hypoglycaemia present?

A
  • Neonatal - confusion, jitteriness, seizures, coma, apnoea *maybe asymptomatic
  • children and young
    • complaints of hunger, unsettled tummy
    • sweatiness, feeling faint, dizzy
    • wobbly legs
    • pounding heart, headache, drowsiness
33
Q

what are some short term complications of hypoglycaemia?

A

transient neurological symptoms such as paresis, convulsions, encephalopathy, loss of consciousness, and rarely, subsequent neurological damage and mild intellectual impairment

34
Q

how is hypoglycaemia managed?

A

neonatal - frequent feeds, if <2 dextrose gel, <1 2 doses of glucose gel and IV dextrose

children - easily absorbable glucose tablets, lucozade
give injection kits to schools
unconscious - hospital for 2ml/kg IV 10% glucose

35
Q

what Is the pathophysiology of malnutrition?

A

rising food prices, global warming, political corruption and war

36
Q

differentiate between marasmus and kwashiorkor?

A
  • marasmus - mixed deficiency of both proteins and calories, non-oedematous decreased weight
  • kwashiorkor - results in oedema, disproportionately low protein intake compared with calorie intake, near normal weight for age and oedema
37
Q

what are some key examination findings for marasmus?

A
  • marasmus - emaciated, ‘old man’ appearance, thin flaccid skin, prominent bones, alert, irritable, distended abdomen
38
Q

what are some key examination findings for kwashiorkor?

A
  • kwashiorkor - BL pitting oedema, apathy, anorexia, skin/hair depigmentation, fragility, distended abdomen
39
Q

what are some complications that could be a result of malnutrition?

A
  • refeeding syndrome from managing
  • head circumference may remain poor
  • infections
  • cognitive impairment
  • other long term health conditions, poor healing
  • reduced strength
  • poor psycho-social function
40
Q

how would you investigate malnutrition?

A
  • heath, weight, BMI
  • bloods: FBC, CRP, U&E for electrolytes, LFT for protein, iron studies, TFT, coeliac serology
  • vitamin levels

*check for co-existing dehydration, infection, anaemia, hypoglycaemia

41
Q

how is malnutrition managed?

A
  • education for families
  • use of supplements
  • acute management
  • whilst reducing risk of refeeding
  • slowly increase high protein diet and vitamins
  • fortified ready to use food etc
  • manage underlying health conditions contributing
42
Q

how would you manage acute malnutrition?

A
  • Refeeding should start at 100 kcal/kg/day, every two hours and is usually with a milk-based formula called F-75
  • immediate vitamin supplementation
  • IV glucose etc
  • week after refeeding give fortified spreads etc
  • Check electrolyte levels once daily for one week and at least three times in the following week
43
Q

who is at high risk of refeeding syndrome?

A

Anorexia nervosa
Cancer
Postoperative debilitation
Uncontrolled DM

Chronic malnutrition:
Marasmus.
Prolonged fasting or low-energy diet
Morbid obesity with profound weight loss
A high-stress patient unfed for >7 days

Malabsorptive syndrome (eg, inflammatory bowel disease, chronic pancreatitis, cystic fibrosis, short bowel syndrome)

44
Q

how do you manage suspected overdose in a child?

A
  • A to E approach to stabilise
  • bloods + toxicology screen
  • ECG etc
  • decontamination with charcoal and gastric lavage
  • antidotes like naloxone, flumazenil, NAC, atropine
  • supportive care and ICU tx
  • psych eval
  • close observation
45
Q

what could cause a pneumothorax in a child?

A
  • spontaneous
  • secondary - asthma, severe pneumonia, CF, foreign body
  • trauma, RTA
  • iatrogenic by mechanical ventilation or drain insertion
46
Q

how might a pneumothorax present?

A
  • neonates: restless, crying, tachypnoea, grunting blue, nostril flare
  • sudden sharp stabbing pain worse with breathing, cough
  • hyper resonance, decreased air entry, deviated trachea
47
Q

how might you investigate a pneumothorax?

A
  • neonates - special light probe which shines brighter with a leak
  • CXR - loss of lung markings etc
48
Q

how would you manage a pneumothorax?

A
  • small ones may not require intervention and may recover on own
  • tension - immediate resuscitation and needle decompression through IV cannula in 2nd intercostal space in midclavicular line on affected side!
  • chest drain into 5th intercostal space in midaxillary line with connection to underwater seal
49
Q

why might a child have nerve palsies?

A
  • with other injuries like fractures or dislocations
  • birth complications - brachial plexus injury with shoulder dystocia
  • high impact sport causing stretching or compression
  • nerve injuries during surgery
  • medical conditions - carpal tunnel syndrome, diabetes, SLE
50
Q

how would you manage a child with a nerve injury?

A
  • nerve conduction, MRI, USS
  • pain mx
  • manage underlying
  • physio and OT
  • nerve transfer or graft
51
Q

how would you manage brachial plexus injury?

A
  • supportive care
    • avoid lifting child under arms
    • support under head and shoulders
    • place affected arm into clothes first when dressing
  • home exercises, referral to specialty care
    • gentle passive motion of all joints in the upper extremity at home at the nappy change, several times a day, especially shoulder external rotation
52
Q

what are some risk factors for respiratory arrest?

A
  • decreased GCS
  • underlying cardiac
  • anaphylaxis
  • drug ingestion
  • foreign body
  • trauma
  • non accidental injury
53
Q

how would you identify respiratory arrest?

A
  • exhaustion
  • bradycardia
  • unresponsive
  • silent chest
  • significant apnoea
  • central and peripheral cyanosis
54
Q

how would you manage a respiratory arrest?

A

A to E
- may need to intubate
- 5 rescue breaths
- resuscitation if required

55
Q

what could cause AKI?

A
  • pre-renal: sepsis, hypovolaemia, dehydration
  • renal: vascular causes, glomerular causes, aTN, drugs and infection on tubulointerstitial
  • post-renal: stones, strictures etc
56
Q

how would you identify an AKI?

A
  • decreased urine output
  • signs of hypovolaemia or hypervolaemia
  • investigations results like creatinine, urine output, MSU, USS etc
57
Q

how would you manage an AKI?

A

fluid management with fluid challenge 10ml/kg of saline
medication review
escalate to nephrologist
followup

58
Q

why are newborn at more risk for hypothermia?

A
  • large surface area to body mass ratio
  • decreased fat
  • greater water content
  • immature skin
  • poor metabolic system so cannot respond to thermal stress
  • altered skin blood flow
59
Q

how might you identify hypothermia in a baby?

A
  • Cool feet and / or cold skin all over the body
  • Reduced activity / lethargy
  • Poor suck
  • Weak cry
  • Bright red face and extremities, be mindful that dark skinned newborns may be more difficult to assess, use full clinical assessment
  • Slow, shallow and irregular breathing
  • Slow heart beat
  • Respiratory distress
60
Q

how do you manage hypothermia?

A
  • conservative with skin to skin contact, warm room, new warm clothes, aim to raise temp of room to 25
  • blood rewarming with ECHMO if severe
61
Q

what could cause hyperthermia in a child?

A
  • Overheating from incubators, radiant warmers, or ambient environmental temperature
  • Maternal fever
  • Maternal epidural anesthesia
  • Phototherapy lights, sunlight
  • Excessive bundling or swaddling
  • Infection
  • CNS disorders (i.e. asphyxia)
  • Dehydration
62
Q

how might you detect hyperthermia?

A
  • Tachycardia, tachypnea, apnea
  • Warm extremities, flushing, perspiration (term newborns)
  • Dehydration
  • Lethargic, hypotonia, poor feeding
  • Irritability
  • Weak cry
63
Q

how would you manage hyperthermia in a baby?

A
  • move away from source of heat
  • undress
  • lower incubator temp
  • breast-fed regularly to replace fluid
  • monitor temp
  • if severe give baby warm bath 2 degrees lower then body temp
  • cooling devices not recommended
  • IVF

Y4 Paediatrics (16 decks)

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