Emergency - ALTE/Anaphylaxis/Poisoning

Question 1

What is an acute life threatening event (ALTE)?

Answer 1

Occur in infants + combination of apnoea, colour change, alteration in muscle tone, choking or gagging

Most common in infants less than 10 weeks old, may occur on multiple occasions

Question 2

What are the common causes of ALTE?

Answer 2

• Infections – RSV, pertussis
• Seizures
• Gastro-oesophageal reflux (in 1/3 normal infants)
• Upper airways obstruction – natural or imposed
• No cause identified

Question 3

How should an acute illness in a child be acutely managed?

Answer 3

• detailed history and thorough examination to identify problems
• admit infant

Question 4

What are the common investigations used in ALTE?

Answer 4

• baseline investigations
• overnight monitoring of oxygen saturations, respiration, ECG
• blood glucose
• blood gas
• oesophageal pH monitoring
• barium swallow
• bloods - FBC, UEs, LFTs, lactate
• Urine - metabolic studies, microscopy and culture, toxicology
• CXR
• LP

Question 5

What is the pathophysiology of an anaphylactic shock?

Answer 5

IgE mediated reaction with significant respiratory or CV compromise

Question 6

What are the common causes of anaphylaxis?

Answer 6

• Food allergy
• Insect stings
• Drugs
• Latex
• Exercise
• Inhalant allergens
• Idiopathic

Question 7

What are the risk factors for a fatal outcome in anaphylaxis?

Answer 7

adolescent age group
coexistent asthma
nut allergy

Question 8

What are the common presenting features of anaphylaxis?

Answer 8

• cutaneous/ocular: flushing, urticarial, angioedema, cutaneous and/or conjunctival pruritus, warmth & swelling
• respiratory: nasal congestion, rhinoorhea, throat tightness, wheezing, SOB, cough, hoarseness
• CV: dizziness, weakness, syncope, chest pain, palpitations
• GI: dysphagia, N&V, diarrhoea, bloating, cramps
• Neurologic: headache, dizziness, blurred vision, seizure

Question 9

What are the immediate management stages in anaphylactic shock?

Answer 9

ABCDE
Assess and diagnose where problem is occurring
Call for help
Put patient in supine position with legs raised
Adrenaline 1:1000 IM

if available:
establish airway 
high flow oxygen 
IV fluid 
chlorpheniramine - IM or slow IV
hydrocortisone - IM or slow IV 

monitor:
pulse
ECG
BP

Question 10

What is the long term management of anaphylaxis?

Answer 10

detailed strategies and training for allergen avoidance
written management plan with instructions for treatment of allergic reactions
provision of adrenaline auto-injectors

Question 11

What investigations are used in anaphylaxis?

Answer 11

rarely used unless diagnosis is unclear

• plasma histamine or urinary histamine metabolites
• skin testing
• serum tryptase measurements

Question 12

What is the best out of hospital management for anaphylaxis?

Answer 12

epipen

Question 13

When is accidental poisoning common in children?

Answer 13

young children with peak age at 30 months

most occur in child’s own home, when supervision inadequate

Question 14

When is deliberate harm through overdose/self injury most common?

Answer 14

older children

Question 15

What are the common presenting features of paracetamol overdose?

Answer 15

gastric irritation

liver failure after 3-5 days

Question 16

What is the management of a paracetamol overdose?

Answer 16

check plasma conc 4 hours after ingestion
start IV acetylcysteine if plasma conc high
monitor prothrombin time, LFTs and plasma creatinine

Question 17

How does an iron overdose present?

Answer 17

D&V, haematoemesis, melaena, acute gastric ulceration
Latent period of improvement
Later - coma, shock, liver failure
Long term - gastric strictures

Question 18

How is an iron overdose managed?

Answer 18

Serious toxicity if >60mg/kg elemental iron
AXR to count number of tablets
Serum iron levels
Gastric lavage considered in severe cases if <1 hour after ingestion
IV desferrioxamine for chelation

Question 19

How does an alcohol overdose present?

Answer 19

Hypoglycaemia
Coma
Respiratory failure

Question 20

How is an alcohol overdose managed?

Answer 20

Monitor blood glucose
IV glucose if necessary
Blood alcohol levels for severity

Question 21

How does the ingestion of detergents present?

Answer 21

dyspnoea 
dysphagia 
oral pain 
cheek pain 
abdominal pain 
N&V

Question 22

How is the ingestion of detergents managed?

Answer 22

no emesis /gastric lavage
no chemical antidotes as they produce heat
early endoscopy

Question 23

How does an NSAID overdose present?

Answer 23

N&V
electrolyte abnormalities
altered consciousness level 
tachypnoea 
even coma 
may be multiple organ failure and seizures 
abdo pain with tinnitus and nystagmus

Question 24

How is an NSAID overdose managed?

Answer 24

assess ABC and stabilise the patient
GI decontamination with activated charcoal
orogastric lavage

Question 25

How does a methadone overdose present?

Answer 25

Gradual onset that is prolonged

Respiratory depression, CNS depression + pin point pupils

Question 26

How is a methadone overdose managed?

Answer 26

If comatose + respiratory depression, naloxone

Consider gastric lavage

Question 27

What resources are available in dealing with children in overdose?

Answer 27

A&E
CAMHS assessment
Social worker involvement

Question 28

What are the important social family factors in these children?

Answer 28

•Early aggressive behaviour
•Lack of parental supervision
•Academic problems
•Undiagnosed mental health problems
•Peer substance abuse
•Drug available
•Poverty
•Peer rejection
•Child abuse or neglect
- safeguarding issues ***

Question 29

What is sudden infant death syndrome?

Answer 29

sudden and unexpected death of an infant or young child for which no adequate cause is found after a post mortem

Question 30

What are the RF for SIDS?

Answer 30

most common at 2-4 months of age 
RFs 
- preterm 
- male sex
- multiple births 
- GI reflux 
- parents: low income, poor/overcrowded house, young maternal age, smoking 
- environment - lying face down, overheating

Question 31

What are the risk factors for adolescents who overdose or self harm?

Answer 31

• male
• living alone
• social class 5
• psychiatric illness
• alcohol dependence
• physical illness
• FH of depression, alcohol dependence
• recent adverse life events

Question 32

What advice should be given to parents about avoidance of SIDS?

Answer 32

infants should be put on their backs
overheating should be avoided
place infants with feet at bottom of bed so they don’t slip under covers
do not smoke

Question 33

What happens following an unexplained death of a child?

Answer 33

resuscitation if appropriate
care of parents - history 
baby pronounced dead 
investigations - NP aspirate, bloods, LP 
break news to parents
parents are able to hold their baby 
strategy discussion 
home visit with 24 hours 
post-mortem 
case discussion 
follow up and bereavement counselling