Emergency Flashcards
what is the pathophysiology of croup?
- acute infective URTI affecting young children aged 6m-2yrs
- causes oedema in larynx - mucosal inflammation between nose and trachea
- parainfluenza virus, other influenza, adenovirus
what are the key points in a history for croup?
- 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
what are some examination findings for croup?
- stridor
- high pitched wheeze
- or chest may sound normal
- resp distress signs
what are some complications for croup?
complications - lymphadenitis, otitis media, dehydration, rarely bacterial superinfection and very rarely pulmonary oedema and pneumothorax
what are some differentials for croup?
epiglottitis
inhaled foreign body
inhaled noxious substance
acute anaphylaxis
diphtheria
peritonsilar abscess
vocal cord paralysis
what are the initial investigations for croup?
- 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
how is croup managed?
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
when would you consider admission in croup?
- 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
what is the pathophysiology of dehydration?
- 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
what are some key points in history of dehydration?
- recent ongoing fluid loss like D+V
- quantity of fluid loss
- E+D
- urinary hx
how might mild dehydration present on examination?
- mild: dry mucous membranes, thirsty child, cool peripheries, decreased urine output
how might moderate dehydration present on examination?
- moderate: dry mucous membranes, cold peripheries, oliguria, reduced skin turgor, sunken eyes, sunken fontanelle, high HR, raised CRT, irritable, lethargic
how might severe dehydration present on examination?
- severe: moderate + weak, thready pulse, anuria, reduced consciousness, raised RR, shock
what are some red flags on examination for dehydration?
- Appears unwell or deteriorating
- Altered responsiveness
- Sunken eyes
- Reduced skin turgor
- Tachycardia
- Tachypnoea
*hypernatraemic dehydration
how might hypernatraemic dehydration present?
more water than sodium lost from body
- Jittery movements
- Increased muscle tone
- Hyperreflexia
- Convulsions
- Drowsiness or coma
how is dehydration managed?
- oral hydration solution
- IVF given
- manage fluids after rehydration
what is a febrile convulsion?
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
how might febrile convulsions present?
- fever 38c<
- age 6m to 6y
- tonic clonic seizure usually on first day of fever
- infection related
what are some important questions to ask regarding febrile convulsions?
- has child been vaccinated?
- are they at school?
- previous treatment with Abx?
- any history of trauma or toxin ingestion?
- FHx?
- developmental history
what are some red flags regarding febrile convulsions?
- meningism
- complex seizures
- febrile status epilepticus
- CNS infections
*complications recurrence
what are some risk factors for febrile convulsions?
age of onset less than 18m
shorter durations
low grade fever with seizure (<40c)
multiple in same episode
day nursery attendance
FHx
what are some investigations done for febrile convulsions?
- 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
how is a febrile convulsion managed?
*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
how is DKA characterised?
acidosis - pH below 7.3 or bicarb <15
ketonaemia - blood ketones above 3
blood glucose over 11
what is the pathophysiology of DKA?
absolute insulin deficit caused by autoimmune destruction of pancreatic beta cells means ‘starvation midst of plenty’ where body cannot utilise the glucose for metabolism
what does DKA cause?
- 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!
what are some RF for DKA?
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
how might DKA present?
- generally unwell
- lethargy
- N+V
- abdo pain
- sx of shock etc
How is DKA investigated?
- 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
how is DKA managed?
- 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
what is the pathophysiology of hypoglycaemia?
- transient neonatal hypoglycaemia
- in those with DM missed meal, excessive dosing, alcohol ingestion, exercise
how does hypoglycaemia present?
- 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
what are some short term complications of hypoglycaemia?
transient neurological symptoms such as paresis, convulsions, encephalopathy, loss of consciousness, and rarely, subsequent neurological damage and mild intellectual impairment
how is hypoglycaemia managed?
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
what Is the pathophysiology of malnutrition?
rising food prices, global warming, political corruption and war
differentiate between marasmus and kwashiorkor?
- 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
what are some key examination findings for marasmus?
- marasmus - emaciated, ‘old man’ appearance, thin flaccid skin, prominent bones, alert, irritable, distended abdomen
what are some key examination findings for kwashiorkor?
- kwashiorkor - BL pitting oedema, apathy, anorexia, skin/hair depigmentation, fragility, distended abdomen
what are some complications that could be a result of malnutrition?
- 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
how would you investigate malnutrition?
- 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
how is malnutrition managed?
- 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
how would you manage acute malnutrition?
- 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
who is at high risk of refeeding syndrome?
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)
how do you manage suspected overdose in a child?
- 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
what could cause a pneumothorax in a child?
- spontaneous
- secondary - asthma, severe pneumonia, CF, foreign body
- trauma, RTA
- iatrogenic by mechanical ventilation or drain insertion
how might a pneumothorax present?
- neonates: restless, crying, tachypnoea, grunting blue, nostril flare
- sudden sharp stabbing pain worse with breathing, cough
- hyper resonance, decreased air entry, deviated trachea
how might you investigate a pneumothorax?
- neonates - special light probe which shines brighter with a leak
- CXR - loss of lung markings etc
how would you manage a pneumothorax?
- 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
why might a child have nerve palsies?
- 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
how would you manage a child with a nerve injury?
- nerve conduction, MRI, USS
- pain mx
- manage underlying
- physio and OT
- nerve transfer or graft
how would you manage brachial plexus injury?
- 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
what are some risk factors for respiratory arrest?
- decreased GCS
- underlying cardiac
- anaphylaxis
- drug ingestion
- foreign body
- trauma
- non accidental injury
how would you identify respiratory arrest?
- exhaustion
- bradycardia
- unresponsive
- silent chest
- significant apnoea
- central and peripheral cyanosis
how would you manage a respiratory arrest?
A to E
- may need to intubate
- 5 rescue breaths
- resuscitation if required
what could cause AKI?
- pre-renal: sepsis, hypovolaemia, dehydration
- renal: vascular causes, glomerular causes, aTN, drugs and infection on tubulointerstitial
- post-renal: stones, strictures etc
how would you identify an AKI?
- decreased urine output
- signs of hypovolaemia or hypervolaemia
- investigations results like creatinine, urine output, MSU, USS etc
how would you manage an AKI?
fluid management with fluid challenge 10ml/kg of saline
medication review
escalate to nephrologist
followup
why are newborn at more risk for hypothermia?
- 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
how might you identify hypothermia in a baby?
- 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
how do you manage hypothermia?
- 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
what could cause hyperthermia in a child?
- 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
how might you detect hyperthermia?
- Tachycardia, tachypnea, apnea
- Warm extremities, flushing, perspiration (term newborns)
- Dehydration
- Lethargic, hypotonia, poor feeding
- Irritability
- Weak cry
how would you manage hyperthermia in a baby?
- 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
