Emergency Paediatrics Flashcards
What do you do if a child has NICE traffic light
a) amber signs
b) red signs
a) can go home with strict safety netting or refer to hospital
b) immediate transfer to hospital
What are the NICE traffic light amber signs?
- pale
- reduced activity, wake with stimulation
- nasal flaring, sats <95%
- poor feeding, reduced UO
- temp >39
What are the NICE traffic light red signs?
- blue, mottled
- not rousable, high pitched cry
- grunting or chest indrawing or RR >66
- reduced skin turgor
- temp >38 if <3 months old
- bulging fontanelle, non blanching rash, seizures
What is grunting?
Trying to maintain PEEP - creates an end pressure to prevent the alveoli from closing
What are the signs of potential circulatory failure?
Cap refill - sternum for 5 seconds BP, HR Urine output Skin colour/temperature - skin mottling Look for resp failure, distress, agitation, conscious level, rapid deep breathing due to metabolic acidosis Drowsy, still child, unresponsive
What are signs of potential central neurological failure?
Conscious levels - AVPU, GCS
GCS of 8 - unresponsive that you no longer protect airway, so may need to intubate, aprox P of AVPU
Posture
Pupillary signs
What are red flags in children?
Hypoxia - can compensate for long time
Hypotension
Silent chest
Unequal pupils - late sign, raised ICP dilatation pressure on oculomotor means herniation
(fixed and dilated - dead, one reactive - one squished)
Posturing - decorticate vs decerebrate can indicate brain injury or herniation occurring/about to occur
What congenital heart defect is the most common cause of heart failure?
VSD
What are the types of poisoning in a child?
Accidental
Deliberate by older sibling
Non accidental - abuse
Iatrogenic
What are examples of potential accidental poisonings?
Low - COCP, abx, chalk, crayons, washing powder
Intermediate - paracetamol, salbutamol, bleach, disinfectants, foschia
High - alcohol, digoxin, iron, salicylate, TCAs, acids, yew
What are the clinical features of poisons?
Aspirin, CO - tachypnoea Opiates - resp depression Alcohol - resp depression TCA, beta blocks - hypotension TCA, organophosphates - convulsions TCA, drugs - large pupils Organophosphates - small pupils
What is the management of poisoning?
Identify agent
Assessment of agent’s toxicity via TOXBASE
Removal of poison:
Activated charcoal, ineffective for iron, insecticides, aspiration can cause pneumonitis
By NG or oral
Gastric lavage, rarely used in children only if large quantity
Induced vomiting with ipecac rare
Investigations:
Blood glucose - alcohol
Blood levels
Toxicology screen
Plan clinical management Low toxicity - home Intermediate - observe High - admit Specific antidotes
Assess social circumstances
What is the management for button batteries?
Monitor progress with chest and abdo x-rays
Almost all pass within 2 days
Remove batteries if in oesophagus or sign of disintegration
What injuries may a child suffer with trauma?
Abdominal injuries e.g. ruptured spleen, liver, kidney
Scans, x-rays, observation
Chest injuries - pneumothorax, haemopericardium
What is the management of burns and scalds?
Is airway, breathing, circulation satisfactory
Any smoke inhalation
Depth of burn - if full thickness will require graft
Surface area of burn
Involvement of special sites
What primary damage occurs from head injuries in children?
Cerebral contusions or lacerations
Dural tears
Diffuse axonal damage
What secondary damage occurs from head injuries in children?
Hypoxia from airway obstruction, or inadequate ventilation
Hypoglycaemia
Hyperglycaemia
Reduced cerebral perfusion due to hypotension from bleeding, raised ICP
Haematoma, infection from open wound or CSF leak
What is the primary survey in a head injury?
A-E assessment
What indicates a potentially serious head injury?
Witnessed LOC >5 mins
Amnesia >5 mins
Abnormal drowsiness
3 or more episodes of vomiting
Clinical suspicion of NAI
post traumatic seizure, but no history of epilepsy
GCS <15
Suspicion of open/depressed skull injury, tense fontanelle
Basal skull fracture signs - panda eyes, battle sign, haemotympanum
Dangerous mechanism e.g. fall, RTA, high speed object
What are signs of secondary damage?
Persisting coma
Deteriorating GCS
Seizures without full recovery
Focal neurological signs
What is the immediate management of a potentially serious head injury?
Immediate CT head scan
Assess need for cervical spine imaging
Observation
Any evidence of secondary damage, penetrating injury or CSF leak - neurosurgical referral
What is wound management from e.g. dog bites?
Copious wound irrigation, debridement Removal of foreign bodies Delayed wound closure Raise and immobilise limb Regular wound review Tetanus booster Prophylactic antibiotics - co-amoxiclav
What is the management of airway obstruction from a foreign body?
Assess severity
If effective cough - encourage to cough, continue to check for deterioration
Ineffective cough
Unconscious - open airway, 5 breaths, start CPR
Conscious - 5 back blows, 5 thrusts or chest for infant
What is the assessment of the seriously ill child?
Airway and breathing Look for obstruction, distress Work of breathing, rate Stridor or wheeze Auscultation for air entry Cyanosis
Circulation - HR, CRT, BP
Disability
LOC, posture, pupil size and reactivity
What are causes of hypovolaemia?
Dehydration - gastroenteritis
DKA
Blood loss -trauma
What can cause maldistribution of fluid?
Septicaemia
Anaphylaxis
What can cause cardiogenic shock?
Arrhythmias
Heart failure
What can cause respiratory distress?
Upper airway obstruction: causes stridor Croup/epiglottitis Foreign body Congenital malformations Trauma
Lower airway disorders e.g. asthma, bronchiolitis, pneumonia, pneumothorax
What are surgical emergencies?
Acute abdomen - appendicitis, peritonitis
Intestinal obstruction - intussusception, malrotation, bowel atresia/stenosis
What are the chest compressions for a child?
15 compressions, 2 breaths
100-120 compression/min
What are examples of shockable rhythms?
Ventricular fibrillation VF
Pulseless ventricular tachycardia
When can adrenaline be administered in cardiac arrest?
Give adrenaline every 3-5 mins after 3 shock and then at alternate cycles if shockable rhythm
If unshockable rhythm, CPR and adrenaline every 3-5 mins ie every other cycle
What are reversible causes of cardiac arrest?
4Hs and 4Ts
Hypoxia
Hypovolaemia
Hypo/hyperkalaemia
Hypothermia
Tension pneumothorax
Toxins
Tamponade
Thromboembolism
What are the clinical signs of shock?
Tachypnoea, tachycardia Decreased skin turgor Sunken eyes and fontanelle Delayed CRT Mottled pale cold skin Core peripheral temp gap Decreased urinary output
Late - acidotic, bradycardia
Confused, blue peripheries Hypotensive
Absent urine output
What are the clinical features of sepsis?
Fever, poor feeding, misery Lethargy History of focal infection Predisposing conditions Tachycardia, tachypnoea Purpuric rash Shock, multi-organ failure
What are causes of pinpoint fixed pupils?
Opiates, barbiturates
Pontine lesion
What are causes of fixed, dilated pupils?
Severe hypoxia
During/post seizures
Anticholinergic drugs
Hypothermia
What are causes of a unilateral dilated pupil?
Expanding ipsilateral lesion
Tentorial herniation
Third nerve lesion
Seizures
What are apparent life threatening events? ALTE
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
Can be presentation of deadly serious disorder, or no cause identified
What are some causes of a coma and appropriate investigations?
Infection - fever, rash, seizures, neck stiffness
Do FBC, cultures, CSF, PCR
Status epilepticus or post-ictal - hx of seizures, neurocutaneous lesions on skin, developmental delay, ongoing seizure activity
Do blood glucose, electrolytes, drug levels, EEG, CT
Trauma - RTA, bruising, haemorrhage, fractures
Do x-rays, CT, MRI
Diabetes - DKA, diabetes
Blood glucose, plasma electrolytes, urine, blood gas
Hypoglycaemia
Inborn errors of metabolism
Hepatic failure - do LFTs, PT
Acute renal failure - creatinine
Poisoning - toxicology, FBC
Shock - FBC, cultures, urea, blood gases
HTN - left ventricular hypertrophy on ECG or echo
Resp failure - chest x ray, arterial blood gas - hypoxia, hypercarbia
What is the management protocol for status epilepticus?
A-E, check blood glucose
If <3, give glucose IV
If no vascular access - diazepam or midazolam buccal
If IV access lorazepam Repeat if no response in 5-10 mins Paraldehyde PR Phenytoin if no response Rapid sequence induction and mechanical ventilation if still no response
What are some causes to be considered in apparent life threatening events?
Infections - RSV, pertussis Seizures GORD Upper airways obstruction No cause identified
Uncommon - Arrhythmias Breath holding Anaemia Heavy wrapping/heat stress Central hypoventilation syndrome Cyanotic spells from intrapulmonary shunting
What are red flags in a history of acutely swollen joint?
Fever Refusal to weight bear or use affected joint Constant severe pain Night pain Weight loss Unexplained bruising
What are common differentials for an acutely swollen joint?
Infection - septic arthritis, osteomyelitis
Viral arthritis
Trauma - fracture, dislocation, soft tissue injury, child abuse, NAI
Reactive arthritis
Haemophilia - family history, unexplained bruising
Juvenile idiopathic arthritis Kawasaki disease Acute rheumatic fever Henoch-Schonlein purpura Serum sickness
Leukaemia
Soft tissue malignancy
IBD
Ehlers-Danlos
What is croup?
URTI
Toddlers and infants
Stridor due to laryngeal oedema and secretions
Parainfluenza virus cause
What are the features of croup?
Stridor
Barking cough - worse at night
Fever
Coryzal symptoms
What features of croup may prompt admission?
<6 months of age
Known upper airway abnormalities e.g. laryngomalacia, Down’s
Uncertainty about diagnosis
Moderate or severe croup
What are the investigations of croup?
Clinical diagnosis
CXR - PA view subglottic narrowing - steeple sign
What is the management of croup?
Single dose oral dexamethasone regardless of severity
Or prednisolone
High flow oxygen
Nebulised adrenaline
When is the heel prick test completed and what does it test for?
Day 5-9 Hypothyroidism PKU Metabolic diseases CF MCADD
