Emergency Paediatrics Flashcards
Define sepsis
Dysregulated response to infection which may result in organ damage and death
Pathophysiology of sepsis
Pro-inflammatory cascade triggered by an infection which may rapidly lead to shock, organ dysfunction and death
- systemic inflammatory response syndrome in presence of infection
Risk factors for sepsis
Neonates and young babies under 3 months
Premature
History of prolonged rupture of membranes
Maternal intrapartum pyrexia
Maternal colonisation with Group B strep
Immunocompromised children - chemotherapy, immunodeficient or post transplant patients
Features of a history indicative of sepsis
Fever - may be absence of hypothermia in most unwell Lethargy N+V Headache Abdo pain
Signs on examination indicative of sepsis
Signs of shock = severe sepsis with shock
- hypotension
- tachycardia
- cool peripheries
- confusion
Children compensate well
- relatively well child with fever
- tachycardia - disproportionate to fever or continues post-fever
- signs of infection - crackles on chest auscultation, cellulitic skin
- non-blanching rash = meningococcal disease
Differential diagnosis of sepsis
Uncomplicated infection - viral URTI
Leukaemia and aplastic anaemia - can present concurrently with sepsis
- pale, easy bruising, non-blanching rash, fever, lethargy
- picked up on blood film
Autoimmune conditions such as juvenile idiopathic arthiris - hx of rash, swollen joints, fever
Investigations for sepsis
Clinical diagnosis - Raised inflammatory markers - Positive cultures or PCRs In babies under 3 with fever - FBC - CRP - blood culture - urine testing - stool culture - if diarrhoea present Find source of infection - CXR - abdominal USS - LP
High risk features in child under 5 with fever
Pale, mottled, ashed or blue skin No response to social cues Appears ill Does not wake Weak, high pitched continuous cry Grunting Tachypnoea - RR>60 Moderate of severe chest indrawing Reduced skin turgor Age < 3 months, temp > 38 Non-blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs Focal seizures
Amber (immediate risk) factors for child under 5 with fever
Pallor reported by parent/career Not responding normally to social cues No smile Wakes only with prolonged stimulation Decreased activity Nasal flaring Tachypnoea - RR>50 age 6-12 months - RR>40 age >12 months O2 sats < 95% on air Crackles on chest Tachycardia - > 160 age < 12 months - > 150 age 12-24 months - > 140 age 2-5 years CRT > 3 seconds Dry mucous membranes Poor feeding in infants Reduced urine output Age 3-6 months temp > 39 Fever for > 5 days Rigors Swelling of limb/joint Non-weight bearing limb
Low risk factors for children under 5 with a fever
Normal skin colour Responds normally to social cues Content/smiles Tarys awake or awakens quickly Strong normal cry/not crying Normal skin and eyes Moist mucous membranes None of the amber or red symptoms or signs
Immediate management for sepsis in children
Take blood cultures
Check blood lactate
Monitor urine output - catheterise if necessary
Give high flow O2
IV/O fluids
IV/O antibiotics
Children particularly prone to hypoglycemia when unwell - corrected with 2ml/kg bolus of 10% dextrose if blood sugar < 3mmol/L
Definitive management of sepsis in children
Appropriate treatment of underlying infection
Supportive care required whilst antimicrobial therapy takes effect
- may involve intensive care admission for ventilator or inotropic support
Complications of sepsis in children
Long term developmental delay
Audiology defects - testing arranged on discharge
Limb ischaemia -> amputation
Why are children at a greater risk of dehydration
Higher metabolic rates
Inability to communicate thirst or self-hydrate effectively
Greater water requirements per unit weight
Causes of dehydration in children
Inadequate fluid intake
- structural malformation - tongue tie, cleft lip
- discomfort - oral ulcers, tonsillitis, viral pharyngitis, stomatitis
- respiratory distress
- neglect
Excessive fluid loss
- diarrhoea and/or vomiting - gastritis, gastroenteritis, pyloric stenosis, mesenteric adenitis, acute appendicitis, diabetic ketoacidosis
- excessive sweating - strenuous or prolonged physical activity, hot weather, pyrexia
- polyuria - DM, DI
- burns
Key features of history of dehydration
Recent or ongoing fluid losses
Quantity of fluid loss
Are they still eating/drinking
Still urinating
Signs of clinical dehydration
Appears to be unwell or deteriorating Altered responsiveness - irritable, lethargy Decreased urine output Skin colour unchanged Warm extremities Sunken eyes Dry mucous membranes Tachycardia Tachypnoea Normal peripheral pulses Normal CRT Reduced skin turgor Normal blood pressure
Clinical signs of shock
Decreased level of consciousness Pale or mottled skin Cold extremities Tachycardia Tachypnoea Weak peripheral pulses Prolonged CRT Hypotension (decompensated shock)
Red flags for dehydration in children
Appears unwell or deteriorating Altered responsiveness Sunken eyes Reduced skin turgor Tachycardia Tachypnoea
Features of hypernatremic dehydration
More water than sodium lost from body Jittery movements Increased muscle tone Hyperreflexia Convulsions Drowsiness or coma
Management of dehydration
ORS (Dioralyte) 50ml/kg over 4 hours + maintenance requirements
If not tolerating oral fluids
- NG fluids
- IV fluids
Maintenance and correction till rehydration
Investigate cause and reintroduction of normal fluid and foods
Management of shock
IV/IO access 20ml/kg 0.9% normal saline
Blood for FBC, U+Es, glucose, gas, consider cultures
If not improving repeat fluid bolus, then call CICU
When should IV fluids be given to dehydrated children
Shock is suspected or confirmed
Child with red flag symptoms or signs shows clinical evidence of deterioration despite oral rehydration therapy
Child persistently vomits oral rehydration solution given orally or NG
Estimate of fluid deficit in children
Weight (kg) x % dehydration x 10
Fluid management after rehydration in children
Encourage breastfeeding and other milk feeds
Encourage fluid intake
Discourage fruit juices and carbonated drinks
In children at increased risk of dehydration consider giving 5ml/kg of ORS after each watery stool
- children under 1 year
- infants of low birth weight
- children who have passed more than 5 diarrhoeal stools in the previous 24 hours
- children who have vomited more than twice in previous 24 hours
Maintenance fluids for children who are nil by mouth but not yet dehyrated
- 9% sodium chloride and 5% dextrose
- 100ml/kg for first 10kg bodyweight
- 50ml/kg for second 10kg bodyweight
- 20ml/kg for every kg above 20kg
Children at risk of aspiration
Decreased GCS Underlying cardiac condition Anaphylaxis Drug ingestion Neuromuscular disorders Respiratory pathology Foreign body Post cardiac surgery Drowning Trauma Medication that causes reduced GCS Anatomical abnormality
Differential diagnoses of arrest in children
Choking Opiate ingestion Overdose of toxic substance Decreased level of consciousness due to neurological disorder/head injury Hypoglycemia
Algorithm for paediatric life support
Unresponsive - Shout for help - Open airway Not breathing normally - 5 rescue breaths No signs of life - 15 chest compressions - 2 rescue breaths and 15 chest compressions - call resuscitation team - 1 min CPR first if alone
Approach to seriously ill child
Primary ABCDE assessment and resuscitation
Secondary assessment and emergency treatment
Stabilisation and transfer
Stages of primary ABCDE assessment in children
Airway and breathing - effort of breathing - resp rate and rhythm - stridor/wheeze - auscultation - skin colour Circulation - heart rate - pulse volume - cap refill - skin temp Disability - conscious level - posture - pupils Exposure - fever - rash - bruising
Features of airway assessment in children
Head tilt chin lift - neural in an infant - sniffing position in child Then try jaw thrust In hospital adjuncts such as naso-pharyngeal airways or Guedel airways can be used
Features of breathing assessment in children
Effort of breathing
- Raised resp rate - may be caused by airway or lung pathology or driven by metabolic acidosis
- Gasping is a late sign of distress
Efficacy
- observation of chest expansion and auscultation
- silent chest most worrying
Effect of resp insufficiency
- tachycardia but will leave to bradycardia
Resuscitation
- high flow O2 through oxygen mask with reservoir bag
- if inadequate resp effort then use a bag-valve mask and consider intubation
- if patient coughing encourage coughing then 5 back blows followed by 5 chest thrusts
Features of circulation assessment in children
Record HR, pulse volume, cap refill time and BP
Children are good at compensating for alterations so hypotension a late sign
Resuscitation
- 20ml/kg bolus of 0.9 sodium chloride
- intraosseous access is rapid and effective - considered early if difficult cannulation
Features of disability assessment in children
AVPU score
- Alert
- V responds to voice
- P responds to pain
- Unresponsive
Most children will be floppy when seriously ill
- stiff posturing suggests serious brain dysfunction
Record pupil size and response to light, blood sugar
Features of secondary assessment in children
Reassessing response to initial resuscitative measures
Taking focused hx
Performing detailed systemd based examinations
Further investigations - blood tests, ECG, radiographs, CT
Diagnosis and emergency treatment of bubbling sounds on auscultation
D = excessive secretions ET = suctioning
Diagnosis and emergency treatment of harsh stridor and barking cough
D = croup ET = oral dexamethasone, nebulised budesonide and adrenaline in severe cases
Diagnosis and emergency treatment of soft stridors, drooling and fever
D = Bacterial tracheitis or epiglottitis ET = intubation by anaesthetist followed by IV abx
Diagnosis and emergency treatment of sudden onset stridor with history of inhalation
D = inhaled foreign body ET = laryngoscopy for removal
Diagnosis and emergency treatment of stridor following ingestion or injection of known allergen
D = anaphylaxis ET = IM adrenaline
Diagnosis and emergency treatment of wheeze
D = acute asthma ET = bronchodilators
Diagnosis and emergency treatment of bronchial breathing
D = pneumonia ET = IV antibiotics
Management of congenital heart disease
May present in first few days on life in ED - heart still undergoing changes from foetal to neonatal circulation
Closure of ductus arteriosus
- presentations vary from subtle symptoms of poor feeding, sleepiness and slightly fast breathing to collapse in cardiogenic shock
If duct dependent lesion suspected IV dinoprostone should be administered
Management of supraventricular tachycardia
Older children present with episodes of palpitations, chest pain and dizziness
Babies may present with signs of heart failure, following prolonged episodes of SVT
Identified on 12 lead ECG
Treatment involves vagal maneuvers followed by rapid bolus of IV adenosine or synchronous DC shock
Management of seizures in children
Most children will present post seizure in a stable condition to ED
Status epilepticus - seizure activity ongoing at 20 mins or shorter seizures with incomplete recovery between
- Midazolam 0.5 mg/kg buccally or Lorazepam 0.1 mg/kg if intravenous access established
Epidemiology of choking
80% of episodes occurring in 1-3 age groups
- peak frequency between 1-2 years
Risk factors of child choking
Playing with small parts
Unsupervised play and eating
Children with decreased consciousness
Differential diagnosis of child choking
Acute epiglottitis - sitting forward, drooling, toxic looking, temperature
Croup - coryzal symptoms, cough associated, improved with steroids/adrenaline nebuliser
Laryngomalacia - present from early age and improves with age
Whooping cough - unimmunised child, cough associated, coryzal symptoms with associated temperature
Reduced GCS - can cause stridor
Management of child choking
Remove foreign body if easily seen
- do not perform blind finger sweep - can push foreign body further into airway
Encourage coughing
5 back blows then 5 chest thrusts/abdominal thrusts
- check each time to see object came out
If unconscious
- open airway, 5 rescue breaths and start CPR
Define ALTE
Apparent Life Threatening Event
- an episode that is frightening to observer
- may include apnoea, choking or gagging, colour change or change in tone
- new term is BRUE
Define BRUE
Brief Resolved Unexplained Event
- an event occuring in an infant younger than 1 year when the caregiver reports a sudden brief and now resolved episode of
- cyanosis or pallor
- absent, decreased or irregular breathing
- marked change in tone
- altered level of responsiveness
Pathophysiology of BRUE
In 50% of patients cause is identified
- GORD is most common cause
Risk factors for BRUE
Infants < 2 months old
Infants under 30 days old
Patients who were premature and previous event
Management of BRUE
Reassurance and observations
For low risk patients
- observation may occur in ED then safety net before discharge
For high risk patients
- refer to paediatric team for admission with investigations
Characteristics of DKA
Acidosis - blood pH below 7.3 or plasma bicarb below 15mmol/L
Ketonaemia - blood ketones above 3 mmol/L
Blood glucose levels generally high - above 11 mmol/L
Complications of DKA
Cerebral oedema
Hypokalaemia
Aspiration pneumonia
Pathophysiology of DKA
Starvation in midst of plenty
- blood glucose levels raised but cannot be used due to absolute deficiency of insulin
Rise in counter-regulatory hormones including glucagon, cortisol , catecholamines and growth hormone
Raises blood glucose and accelerated break down of adipose tissue
- rising level of acidic ketone bodies
Leads to osmotic diuresis so patient becomes polyuric -> dehydration
Vomiting common in DKA
Risk factors for DKA
Lack on insulin - non-compliance with insulin treatment - device failure - changing insulin requirements during puberty An excess of glucose - increased ingestion of glucose Intercurrent illness - infection
Symptoms of DKA
Generally unwell and lethargic
N+V
Abdo pain
Cerebral oedema - headache, irritability, progressing to confusion, drowsiness or collapse
Symptoms of DM
Weight loss
Polyuria
Polydipsia
Clinical features of DKA
Deep, sighing breathing (Kussmaul breathing)
Tachypnoea
Subcostal and intercostal recessions
Shock - tachycardia, hypotension, increased CRT, cool peripheries
Dehydration - dry mucous membranes, sunken eyes/fontanelle and reduced skin turgor
Abdo pain
Reduced consciousness
Papilloedema
Non-specific weakness, general malaise and ketotic breath
Differential diagnosis of DKA
Hyperosmolar Hyperglycaemic State - usually occurs in DMT2 - no ketone production or acidosis - serum osmolality > 320mosmol/kg New presentation of T1DM Dehydration Sepsis Surgical abdomen Acidosis from renal failure or substance ingestions
Investigations for DKA
Bedside blood glucose and ketones from finger prick
- urinary ketones on dipstick
Blood gas
Lab samples - blood glucose, U&Es, FBC and creatinine
12 lead ECG
Levels of DKA severity
Mild - venous pH 7.2-7.3 or bicarbonate < 15mmol/L
- 5% dehydration
Moderate - venous pH 7.1-7.2 or bicarbonate < 10mmol/L
- 7% dehydration
Severe - venous pH less than 7.1 or bicarb < 5mmol/L
Management of DKA
Those presenting with shock 20ml/kg bolus of 0.9% saline over 15 mins
Those not in shock receive 10ml/kg bolus over 60 mins
Calculate fluid requirement
- requirement = deficit + maintenance
Insulin 0.05 or 0.1 units/kg/hour by infusion 1-2 hours after starting IV fluids
Re-evaluate
If blood glucose < 14mmol/L add 5% glucose to 0.9% sodium chloride with 20 mmol KCL per 500ml
Start subcut insulin then stop IV insulin 1 hour later
Resolution of DKA
Child clinically well, drinking well, tolerating food
Blood ketones < 1.0mmol/l or pH normal
Urine ketones may still be positive
Red flags for leg pain/limp
Worse - in the morning -> inflammatory arthropathy - at night -> malignancy Systemically unwell - night sweats, weight loss -> malignancy, infection, inflammatory Redness and swelling over joint -> infection of inflammatory Unexplained rashes or bruises -> coagulopathy of ?NAI
Causes of leg pain/limp in children
<3 years - Toddler's fracture 3-10 years - Transient synovitis - Perthes' disease 10-18 years - Slipped capital femoral epiphysis Any age group - Fracture - Septic arthritis - Osteomyelitis - Malignancy - Inflammatory arthropathies
Epidemiology of Toddler’s fracture
9 months - 3 years of age
Pathology of Toddler’s fracture
Minimally displaced spiral fractures of tibia
- rarely related to NAI
Features of a Toddler’s fracture
Unable to weight bear
Tender tibial diaphysis
Normal obs
Ix for Toddler’s fracture
Subtle fracture on radiograph
Epidemiology of transient synovitis
Most common cause of hip pain in 3-10 year old
Associated with viral upper respiratory tract infection
Pathology of transient synovitis
Synovial inflammation following an URTI
Presentation of transient synovitis
Afebrile Limp Refusal to weight bear Groin or hip pain Mild low grade temperature Slightly reduced ROM
Ix for transient synovitis
Mildly raised WCC and ESR
CRP < 20mg/L
Management of transient synovitis
Symptomatic - simple analgesia to ease discomfort Safety net - if symptoms worsen or develop a fever report to A&E - follow up at 48 hours and 1 week
Define Perthes disease
Idiopathic avascular necrosis of the femoral head
Disruption of blood flow to femoral head -> avascular necrosis of the bone
- affects the epiphysis of femur
Epidemiology of Perthes disease
4-12 year olds - mostly between 5-8 years
More common in boys
Presentation of Perthes disease’
Pain in hip or groin Limp Restricted hop movements Maybe referred pain to knee Afebrile Reduced internal rotation
Ix for Perthes’ disease
Bloods normal Radiograph - sclerosis in femoral head - fragmentation of femoral head - widening and flattening of femoral head MRI and bone scan
Mx of Perthes’ disease
Maintain healthy position and alignment in joint and reduce the risk of damage/deformity
- bed rest
- traction
- crutches
- analgesia
Physiotherapy
- retain ROM without putting excess stress on the bone
Regular x rays
- assess healing
Surgery
- in severe cases, older children and those not healing
- improve alignment and function of femoral head and hip
Epidemiology of slipped capital femoral epiphysis (SCFE)
More common in boys
8-15 years
More common in obese children
Presentation of SCFE
Slippage of the proximal femoral growth plate
- acute or chronic
Hx of minor trauma
Clinical features of SCFE
Hip, groin, thigh or knee pain Restricted ROM Painful limp Prefer to keep externally rotated hip - ROM particularly restricted internal rotation Afebrile
Ix of SCFE
Bloods normal
Radiographs
- frog leg view required to show subtle slips
CT or MRI scan
Mx of SCFE
Surgery required to return the femoral head to correct position and fix it to prevent further slipping
Define septic arthritis
Infection inside joint
Epidemiology of septic arthritis
Most common in children under 4 years - can present at any age
Common and important complication of joint replacement
Presentation of septic arthritis
Hot, red, swollen and painful joint - only affects on joint
Refusing to weight bear
Stiffness and reduced range of motion
Systemic symptoms such as fever, lethargy and sepsis
Pathophysiology of septic arthritis
Haematogenous spread of microorganisms or rarely penetrating injury
Common bacteria causing septic arthritis
Staphylococcus aureus - most common Neisseria gonorrhoea - sexually active teenageers Group a strep - streptococcus pyogenes Haemophilus influenza Escherichia coli
DDx for septic arthritis
Transient synovitis
Perthes disease
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis
Ix for septic arthris
Increased WCC, CRP > 20 and ESR
Joint aspiration - sent for gram staining, crystal microscopy, culture and antibiotic sensitivities
Mx of septic arthritis
Empirical IV abx
- until microbial sensitivities known
- continued for 3-6 weeks
May require surgical drainage and washout
Define osteomyelitis
Infection of bone and bone marrow
Pathophysiology osteomyelitis
Typically occurs in metaphysis of long bones
Commonly staphylococcus aureus
Presentation of ostoemyelitis
Can present acutely with an unwell child or chronically with subtle features Refusing to use the limb or weight bear Pain Swelling Tenderness May be afebrile or low grade fever
Risk factors for osteomyelitis
Open bone fracture Orthopaedic surgery Immunocompromised Sickle cell anaemia HIV Tuberculosis DM
Ix of osteomyelitis
X-rays - can be normal MRI Raised CRP, ESR and WCC Blood culture - establish culture
Mx of osteomyelitis
Prolonged abx therapy
Surgery for drainage and debridement of infected bone
Causative organisms for osteomyelitis
Neonates - Group B strep
6 months to 3 years - Kingella kingae
All ages - S.aureus and S.pneumoniae
Sickle cell disease - Salmonella spp.
Define osteosarcoma
Bone cancer
Epidemiology of osteosarcoma
Presents in adolescents and younger adults 10-20 years
Most commonly the femur, can also be tibia and humerus
Presentation of osteosarcoma
Persistent bone pain - worse at night time Bone swelling Palpable mass Restricted joint movements
Ix for osteosarcoma
Urgent xray - poorly defined lesion of the bone - periosteal reaction - irritation of lining of bone Raised ALP CT/MRI scan Bone biopsy
Mx of osteosarcoma
Surgical resection of lesion
- often with limb amputation
Adjuvant chemotherapy improves outcomes
Complications of osteosarcoma
Pathological bone fractures
Metastasis
Causes of pyrexia of unknown origin
Infectious - Kawasaki disease - TB - typhoid fever - malaria - infectious mononucleosis - HIV Connective tissue disorders - juvenile idiopathic arthritis - SLE - sarcoidosis Inflammatory - UC - crohn's disease Neoplastic - lymphoma - leukaemia Endocrine - hyperthyroidism Other - factitious disorders or FII
