Emergency Flashcards
What is acute life-threatening event (ALTE)
Sudden Often apnoea Colour change Alteration in muscle tone Choking Gagging
Most commonly in infants <10 weeks old - may reoccur
(potentially serious disorder or no cause)
Prognosis of ALTE
Most cases, brief episode with rapid recovery
Baseline investigations and overnight monitoring for Oxygen sats, RR, and ECG normal
Common causes of ALTE
Infections (RSV, pertussis)
Seizures
GORD (1/3 of infants)
Upper airway obstruction (natural or imposed)
Immediate management of an acutely ill child
Stimulation or resuscitation to reinitiate regular breathing
Detailed history and thorough examination
Admission to hospital
Teach resuscitation to parents
Follow up from specialist paeds nurse or paediatrician
Investigations in ALTE
Blood glucose Blood gas and lactate O2 sats monitoring Cardiorespiratory monitoring EEG Oesophageal pH monitoring Barium swallow FBC Urea and electrolytes LFTs Urine - toxicology, culture
ECT (QTc prolongation?)
CXR
Lumbar puncture
Pathophysiology of anaphylaxis
IgE mediated reaction: a previously sensitized B lymphocyte produces IgE against a specific antigen
activation of mast cells and basophils igniting a cascade that results in the release and production of severe inflammatory and vasoactive substances:
histamine, tryptase, heparin, prostaglandins, leukotrienes and cytokines
Physiological processes involved in anaphylaxis
Angioedema Bronchospasm Bronchorrhoea Laryngospasm Increased vascular permeability Decreased vascular tone Bloody diarrhoea
Common agents that cause anaphylaxis in young children
milk egg wheat soy fish shellfish tree nuts
Vaccines Antibiotics (penicillin, cephalosporin) Localanaesthetics Aspirin NSAIDs Opiates Latex Perservatives
Risk factors for anaphylaxis
Younger - smaller airway Asthma Chronic GI symptoms (increases risk of vomiting) Hypotension Bradycardia FHx
Primary diagnostic criteria of anaphylaxis
‘The acute onset of skin and/or mucosal symptoms along with either respiratory compromise and/or reduced blood pressure or associated symptoms of end-organ dysfunction eg. hypotonia, syncope and incontinence’
Very variable:
80% have cutaneous symptoms (eg. hives)
Can also just present with low SBP for age
Skin - urticarial and angioedema
Resp - acute airway obstruction with laryngeal oedema and bronchospasm
GI - severe abdo cramping and diarrhoea
Systemic - hypotension and shock
Onset may be minutes to hours
Management of anaphylaxis (acute)
ABCDE Diagnose the problem: Airway - swelling, hoarseness, stridor Breathing - tachypnoea, wheeze, cyanosis Circulation - pale, clammy, hypotension, drowsy, coma
Put in supine position (30°) with legs raised
Give IV normal saline for hypotension
Adrenaline 1:1000 (give IM unless IV experience)
0.01ml/kg every 15 minutes
Give nebulized salbutamol every 15 min if required (2.5mg if <30kg, otherwise 5mg)
Anti-histamine
Steroid - IV BOLUS methylprednisolone (2mg/kg).
Follow with IV methylprednisolone 2mg/kg/day or oral 2mg/kg/day
Medium term management of anaphylaxis
IV fluid - 20ml/kg crystalloid
Monitor: Pulse oxymetry, ECG, BP
Establish airway and high-flow oxygen
Investigations for anaphylaxis
Serum histamine (rise quickly, then fall after 30-60 min) Serum tryptase levels (peal at 60-90 minutes)
Radioallergosorbent test or cutaneous antigen after recovery to try to identify cause
Role of patient-held medication for anaphylaxis
Epipen
Epinephrin autoinjector. Provided to all people who have had anaphylaxis
Administered IM when signs and symptoms begin.
Can be life-saving
Epidemiology of poisoning
Thousands of admissions per year
Most do not develop serious symptoms
- small quantity or relatively non-toxic
Small percentage become seriously ill
Very few die each year
90% of ingestion occurs in the child home - inadequate supervision/anticipation
Epidemiology of deliberate harm through overdose or self injury
Older children more likely
Recognize as a serious indication of child and family disturbance.
Assessment by adolescent psychiatrist and social worker ideally.
It is thought that 7% (more in teenage girls) have engaged in self-harm
Clinical features of poisons (and which ones?)
Tachypnea - aspirin, carbon monoxide
Slow RR - opiates, alcohol
HTN - amphetamines, cocaine
Hypotension - TCAs, Opiates, B-blockers, Iron
Convulsions - TCAs, organophosphates
Tachycardia - coccaine, anti-depressants, amphetamines
Bradycardia - Beta blockers
Large pupils - TCAs, cocaine, cannabis, amphetamines
Small pupils - opiates, organophosphates
Clinical features of paracetamol ingestion and management
GI irritation and liver failure after 3-5 days
Check plasma concentration 4hrs after ingestion - if >150mg/kg taken, or plasma concentration high, start IV acetylcysteine
Monitor PTT
LFT
Plasma creatinine
Clinical features of NSAID ingestion and management
Nausea
Vomiting
Electrolyte disturbance
Large ingestion can lead to altered level of consciousness, tachypnoea, COMA
Multiple organ failure and seizures
Tinnitus + Nystagmus + abdo pain
Manage:
ABC and stabilize
Activated Charcoal (decontaminates GI)
Orogastric lavage may be needed
Clinical features of iron ingestion
Vomiting Diarrhoea Haematemesis Melaena Acute GI ulceration Followed by latent period of improvement.
Hours later: Drowsiness Coma Shock Liver failure Hypoglycaemia Convulsions
Management of iron poisoning
If serious (>60mg/kg elemental Fe) AXR to count the number of tablets
Serum iron levels.
Consider gastric lavage, especially if severe and <1hr ingestion time
Iv desferrioxamine for chelation may be used
Clinical features of methadone ingestion and management
Pinpoint pupils Constipation Nausea Vomiting Spasms
Low BP
Weak pulse
Shallow, slow breathing
Eventual coma, drowsiness and peripheral shutdown
If no spontaneous ventilation, intubate and give iv naloxone to relieve some resp depression
Clinical features of alcohol ingestion and management
Hypoglycaemia
Coma
Respiratory failure
Monitor blood glucose
Check blood alcohol levels and give IV dextrose if needed
Clinical features of detergent ingestion and management
Dyspnoea Dysphagia Oral pain cheek pain abdo pain N+V
DO NOT induce emesis or try to neutralize the agent.
Dilutant may be used sometimes..
AIRWAY SUPPORT
GASTRIC EMPTYING
DECONTAMINATION (NG tube)
Immediate management of common poisoning agents
Indentify agent (eg parents) Assess toxicity Is removal indicated? (activated charcoal, gastric lavage (rarely in children), induce vomiting with ipecac - rarely)
Investigations? (blood glucose for alcohol, paracetamol, salicylate, iron, digoxin)
Toxicology screen if uncertain about the substance
Plan management:
allow home or
observe for recommended time and discharge if no symptoms or
admit to hospital
Observation and supportive care is usually the mainstay of management
Assess social circumstances to prevent further poisoning accidents
Resources available when dealing with poison ingestion or overdose
Regional poisons information centre for Toxicity
What is the importance of the social family factors in children who overdose
Poor supervision
Abuse?
Purposeful administration?
Little parental support? Poorly cohesive family unit
Risk factors for adolescents who self-harm
Men are more likely to complete suicide.
Divorce > widowed > single
Living alone
Psychiatric illness
Previous deliberate self-harm
Alcohol dependence
Physical illness
FH of depression, alcohol dependence, suicide.
Recent adverse life events (especially bereavement)
Epidemiology of SIDS
Commonest cause of death at ages 1 month - 1 year
Commonest at 2-4months of age
Marked variation in different countries - environmental?
Risk factors for SIDS
INFANT:
Age 1-6months, peak at 12 weeks
Low birthweight and preterm - 60% are normal birthweight
Multiple births
PARENTS: low income poor housing maternal age (<20y/o has higher risk) Single unsupported mother High maternal parity Maternal smoking in pregnancy Parental smoking after birth
The environment:
infant sleeps lying prone
infant overheated from high room temperature and too many clothes, particularly when ill
Give advice to parents about how to avoid SIDS (with some evidence)
SIDS has fallen dramatically in last 20 years, coinciding with the “Back to Sleep” campaign
Infant put to sleep on BACK, not front or side
Avoid overheating with wrapping/high room temperature
Feet to foot position (avoids wriggling under blanket)
Do not smoke near infant (4-8x increased risk)
Seek medical advice promptly if infant becomes unwell
Parents should have the baby in their bedroom for the first 6 months of life.
Avoid bringing baby into bed when tired or have taken alcohol, sedative, medicines or drugs.
Parents should avoid sleeping with the infant on a sofaor armchair
Investigations performed after an infant has been pronounced dead (unexplained)
Nasopharyngeal aspirate for virology and bacteriology.
Blood for toxicology, metabolic screen, chromosomes if there is dysmorphia
Blood culture
Urine (catheter specimen) for biochemistry, toxicology, freeze immediately
Lumbar puncture (CSF for virology and routine culture if clinically indicated)
Breaking news of unexplained death of a child
Break news to parents (paediatrican)
Explain about coroner and police involvement - postmortem is required and some tissue blocks/ sldies will be taken permanently as part of medical record.
Give parents the opportunity to donate tissues and organs.
Inform that the police involvement does not mean that they are being blamed for their child’s death
Procedures after unexplained death of a child
Break news to parents.
Offer parents to see and hold their child (helps to accept the reality of child’s death)
- call in a minister of religion?
Strategy discussion + social services discussion
Police visit home within 24 hours (paediatrician may attend). Get detailed history and compile report for coroner.
Postmortem is performed by paediatric pathologist.
Case discussion (multi-agency: paediatrician, police, GP, social worker if appropriate)
Follow up and bereavement counselling
