Emergency

Question 1

What are acute life threatening events?

Answer 1

o Apnoea
o Colour change
o Alteration in muscle tone
o Choking
o Gagging
• Most commonly occur in infants less than 10 weeks old
episode is brief with a rapid recovery and the baby is clinically well

Question 2

What are the common causes of ALTE?

Answer 2

o Infections- RSV or pertussis
o Seizures
o Gastro-oesophageal reflux, present in 1/3 of normal infants
o Upper airway obstruction, natural or imposed

Question 3

What are the uncommon causes of ALTE?

Answer 3

o	Cardiac arrhythmia
o	Breath-holding
o	Anaemia
o	Heavy wrapping/heat stress
o	Central hypoventilation syndrome
o	Cyanotic spells from intrapulmonary shunting

Question 4

What is the management for ALTE?

Answer 4

detailed history and thorough examination to identify problems with the baby or caregiver
Admit to hospital- multi-channel overnight monitoring is usually indicated
Parents taught resuscitation- helpful to receive follow up from a specialist Paeds nurse

Question 5

What are the investigations for ALTE?

Answer 5

•	Blood glucose
•	Blood gas & lactate
•	Oxygen saturation monitoring
•	Cardiorespiratory monitoring
•	EEG
•	Oesophageal pH monitoring
•	Barium swallow
•	Full blood count
•	Urea & electrolytes and LFTs
•	Urine- collect & freeze 1st sample
o	Metabolic studies
o	MC&S
o	Toxicology
•	ECG- QTc conduction pathway abnormality
•	Chest X-ray
•	Lumbar puncture

Question 6

What is the pathophysiology of anaphylaxis?

Answer 6

• Both IgE and non-IgE mediation involves activation of mast cells and basophils igniting a cascade that results in the release and production of severe inflammatory and vasoactive substances:
these include histamine, tryptase, heparin, prostaglandins, leukotrienes and cytokines
• commonly involve skin, respiratory, cardiovascular and GI systems

Question 7

What are the features of anaphylaxis?

Answer 7

o	Angioedema
o	Bronchospasm
o	Bronchorrhea
o	Laryngospasm
o	Increased vascular permeability
o	Decreased vascular tone
o	Bloody diarrhea

Question 8

What causes the mediators to be released?

Answer 8

IgE mediated reaction
a previously sensitized B lymphocyte produces IgE against a specific antigen
the IgE resides on the mast cells and basophils
when the specific antigen, or one similar to it, binds to the high affinity receptor then degranulation occurs

Question 9

What are the common food triggers for anaphylaxis?

Answer 9

o	Milk
o	Eggs
o	Wheat
o	Soy
o	Fisher
o	Shellfish
o	Tree nuts
o	Legumes

Question 10

What are the other triggers in anaphylaxis?

Answer 10

o	Biologics- venoms & vaccines
o	Drugs- antibiotics (penicillin, cephalosporins), local anaesthetic, analgesics (aspirin & NSAIDs), opiates (codeine & morphine) and radiocontrast media
o	Latex
o	Preservatives & additives-MSG
o	Exercise
o	Inhalant allergens
o	Idiopathic

Question 11

What are the risk factors for anaphylaxis?

Answer 11

o	Younger- smaller airway
o	Asthma
o	Chronic GI symptoms- increases risk of vomiting
o	Hypotension
 o	Bradycardia
o	FHx

Question 12

How can anaphylaxis oddly present?

Answer 12

More than 80% have cutaneous symptoms
Generally 2 organ systems are involved
low SBP for age or a decrease of 30% in SBP after known allergen exposure

Question 13

What is the primary clinical diagnostic criteria for anaphylaxis?

Answer 13

‘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’

Question 14

What is the standard protocol for management in anaphylaxis?

Answer 14

o Adrenaline- SC 0.01ml/kg repeated every 15mins if required
o Hypotension- put the patient head down at 30o and give IV normal saline
o Salbutamol- give nebulized salbutamol 0.05-0.15mg/kg in 3ml normal saline approx. 2.5mg for child <30kg and 5mg for child >30kg every 15mins if required
o Anti-histamine
o Steroid- give IV bolus methylprednisolone (2mg/kg), this dose should be followed by IV methylprednisolone 2mg/kg/day or oral prednisolone 2mg/kg/day

Question 15

What are the investigations for anaphylaxis?

Answer 15

• Serum histamine levels- rise quickly with the onset of symptoms, but do not remain elevated after 30- 60mins
• Serum tryptase levels- peak at 60-90 minutes after the onset of symptoms and remain raised for up to 5hrs
b-tryptase is released with degranulation of mast cells whereas a-tryptase is secreted constitutively by the mast cell- the ratio of total tryptase to b-tryptase can help distinguish systemic mastocytosis from anaphylaxis
o C1 inhibitor functional assay (C1INH)
o Urine vanillymandelic acid (VMA)
o Serum serotonin levels
• Radioallergosorbent test or cutaneous antigen testing can be used after recovery to try to identify the inciting antigen

Question 16

What are the clinical features of poisons?

Answer 16

• Tachypnoea: Aspirin, Carbon Monoxide
• Slow respiratory rate: Opiates, Alcohol
• Hypertension: Amphetamines, Cocaine
• Hypotension: Tricyclics, Opiates, B-blockers, Iron
• Convulsions: Tricyclics, Organophosphates
• Tachycardia: Cocaine, Anti-depressants, Amphetamines
• Bradycardia: B-blockers
• Large pupils: Tricyclics, Cocaine, Cannabis, Amphetamines
• Small pupils: Opiates, Organophosphates

Question 17

What occurs with paracetamol overdose?

Answer 17

adverse effects include GI irritation & liver failure after 3-5 days
check the plasma concentration after 4hrs ingestion if >150mg/kg has been taken, or if plasma conc is high, then start IV acetylcysteine, monitor PTT, LFT & plasma Cr

Question 18

What occurs with NSAID overdose?

Answer 18

Depends of the amount ingested
symptoms include mild nausea, vomiting & electrolyte abnormalities
large ingestion can lead to an altered level on consciousness, tachypnea and even coma
may be multiple organ failure and seizures
tinnitus & nystagmus occur along with abdominal pain
GI decontamination should begin with activated charcoal- orogastric lavage may also be needed

Question 19

What occurs with iron overdose?

Answer 19

initially there is vomiting, diarrhea, haematemesis, melaena & acute GI ulceration
latent period of improvement
hours later, there is drowsiness, coma, shock, liver failure, hypoglycaemia and convulsions
long term this can lead to gastric strictures
if serious toxicity (>60mg/kg elemental Fe), then perform AXR to count the number of tablets
perform serum iron levels and consider gastric lavage, especially if severe and <1hr ingestion time
IV desferrioxamine for chelation may be used

Question 20

What occurs with methadone overdose?

Answer 20

pinpoint pupils, constipation, nausea, vomiting and spasms
there will be a low BP, weak pulse and shallow slow breathing
eventually will lead to coma, drowsiness and peripheral shut down
if the patient lacks spontaneous respiration, then intubate and give IV naloxone to relieve some respiratory depression

Question 21

What occurs with alcohol overdose?

Answer 21

causes hypoglycaemia, coma and respiratory failure

management is to monitor blood glucose, check blood alcohol levels for severity and give IV dextrose if needed

Question 22

What occurs with detergent overdose?

Answer 22

generally very caustic and present with dyspnea, dysphagia, oral pain, cheek pain, abdo pain, N&V
do not induce emesis or try to neutralize the agent
Dilutant may be used
main treatment should be airway support, gastric emptying and decontamination (via NG tube)

Question 23

What is the management for poisoning?

Answer 23

Identification of agent (toxicity, contact regional poisons information centre- TOXBASE)
If <1hr removal indicated- activated charcoal/gastric lavage/induced vomiitng with ipecac
Investigations: glucose (alcohol), blood levels, toxicology screen
Management- low toxicity alow home, intermediate observe and then discharge, high admit to hospital
Assess social circumstances: prevent further poisoning, GP informed, home visit