INTRO TO PAEDS: Resp, Shock, Seizures, Rashes, DKA, UTI, Surgical abdomen Flashcards
What are causes of wheeze + their features?
Asthma = signs of resp distress, personal/family hx of atopy, >5yo
Bronchiolitis = coryzal sx, <5yo, cold months
Anaphylaxis = sudden onset, known trigger, skin: urticaria, ABCD compromise, any age
Pneumonia = fever, productive cough, any age
What are features of moderate asthma exacerbation?
PEFR >50-75%
Normal speech
No severe or life threatening features
What are features of severe asthma exacerbation?
PEFR >33-50%
RR and HR:
- >12yo = RR >25/min, HR >110bpm
- 5-12yo = >30/min, HR >125
- 2-5yo = >40/min, HR >140
Inability to complete sentences/feed
Accessory muscle use
SpO2 >92%
What are features of life-threatening asthma exacerbation?
PEFR <33%
SpO2 <92%
Reduced consciousness/GCS
Exhaustion
Heart arrhythmias
Hypotension
Cyanosis
Reduced respiratory effort
Silent chest
Normalising PCO2
How is a moderate asthma exacerbation treated?
Salbutamol MDI + spacer burst therapy (1 puff every 30-60s, max 10 puffs)
How is a severe asthma exacerbation treated?
Bronchodilators: oxygen driven, nebulised salbutamol (>5yo = 5mg, 2-5yo = 2.5mg), continuous over 30-60mins
intermittent every 20-30 min
Nebulised ipratropium bromide (>12yo = 500mcg, 2-12yo = 250mcg)
Steroids: quadruple ICS or PO prednisolone 5d (>5yo = 30-40mg, 2-5yo = 20mg, <2yo = 10mg) or IV hydrocortisone (>5yo = 100mg, 2-5yo = 50mg)
How is life-threatening asthma treated?
- Nebulised salbutamol + ipratropium bromide
- IV hydrocortisone
- IV magnesium sulphate
- IV aminophylline
- IV salbutamol
What is the chronic management of asthma?
- SABA
- SABA + low dose ICS
- Regular preventer (very low dose ICS or LRTA <5yo)
- Add LRTA or inhaled LABA
- increase ICS dose
- specialist care
How is anaphylaxis treated?
- CALL FOR HELP - lie patient flat + raise legs, stop causative agent
- establish airway, high flow oxygen, IV access + bolus
- IM adrenaline 1:1000, 0.5mg
- IV adrenaline if 3 failed IM (ITU admission)
Monitor for at least 6 hours (risk of 2nd wave)
What are causes of stridor and features of these?
Inhaled foreign object = sudden onset, previously well, unsupervised child, SOB/choking (any age, toddlers esp.) Mx is anaesthetists
Epiglottitis = septic looking, drooling, tripod pose, high fever, sore throat, dysphagia
Anaphylaxis = sudden onset, known trigger, skin (urticaria, angioedema), ABCD compromise
Croup = low grade fever, coryzal sx, seal-like cough, worse at night, hoarse voice. 6mo-6yo
How is epiglottitis managed?
EMERGENCY A-E
1. Secure airway
2. IV ABx = cefotaxime/ceftriaxone
3. Consider corticosteroids
NOTE: avoid looking into throat as high risk of laryngospasm
How is croup managed?
IX = Westley croup score, but mainly base mx off clinical signs and sx
MILD = no stridor at rest, single dose PO dexamethasone
MODERATE = stridor at rest, no agitation/lethargy, single dose PO/IM dex or nebulised budesonide, nebulised epinephrine
SEVERE = stridor at rest agitation/lethargy, single dose PO/IM dex or nebulised budesonide, nebulised epinephrine
What are early signs of shock in a child?
tachypnoea, tachycardia, decreased skin turgor, sunken eyes and fontanelle, delayed CRT, mottled pale or cold skin, core-peripheral temp gap, decreased UO
What are late signs of shock in a child?
Kussmaul breathing, bradycardia, confusion/depressed cerebral state, blue peripheries, absent UO, hypotension
What categories make up the traffic light system and what are red flag features?
COLOUR
- pale/mottled/ashen/blue
ACTIVITY
- unresponsive to social cues
- appears ill to HCP
- unable to be roused or stay awake
- weak, high-pitched or continuous cry
RESP
- grunting
- tachypnoea - RR >60
- moderate or severe chest indrawing
HYDRATION
- reduced skin turgor
OTHER
- age 0-3mths + temp >38
- age 3-6mth + temp >39
- non-blanching rash
- bulging fontanelle
- neck stiffness
- status epilepticus
- focal neurological signs
- focal seizures
- bile-stained vomiting
What are the different tpyes of shock?
Hypovolaemic = excess fluid loss (haemorrhagic or non-haemorrhagic)
Cardiogenic = impaired cardiac function (cardiomyopathies, arrthymias)
Obstructive = obstruction to circulation (tamponade, tension pneumo, emboli)
Distribution = loss of vascular tone (anaphylaxis, septic, neurogenic)
How is sepsis managed?
A-E approach
A = assess airway
B = 15L facemask high flow O2
C = IV/IO abx + fluid resus
- 2 large bore cannulae: 20ml/kg 0.9% saline over 5-10mins
- administer 2nd bolus if still signs of shock
- up to 60ml before considering rx w/vasoactives
- IO access if IV access unattainable (below tibial tuberosity medially)
- take blood gas, lactate, glucose, cultures
- abx = if <3mths cefotaxime + amipicillin, if >3mths ceftriaxone
Consult senior clinicians
Consider inotropic support early (epinephrine, norepinephrine)
If ? or confirmed bacterial meningitis also give 0.15mg/kg dexamethasone
Add IV acyclovir to cover HSV encephalitis
How is status epilepticus managed?
DEFINITION = seizure lasting >5mins
- airway, high flow oxygen, check glucose, protect from injury by cushioning head, removing objects, no restraint
- AT 5 MINS:
- vascular access available = IV/IO lorazepam
- no vascular access = buccal midazolam (or rectal diazepam) - AT 15 MINS:
- IV/IO lorazepam
- call for senior help - Phenytoin (reconfirm it’s an epileptic seizure), consider paraldehyde PR whilst preparing or infusing phenytoin
- AT 25 MINS:
- senior help needed
- seek anaesthetic/ICU advice
- phenytoin IV over 20mins OR if already on it then phenobarbitone IV/IO over 5mins - AT 45 MINS:
- rapid sequence induction of anaesthesia w/thiopental (thiopentone)
- anaesthetist must be present
What are causes of seizures?
METABOLIC = electrolyte abnormalities, hypoglycaemia, hyperglycaemia, inborn errors of metabolism, toxins/poisons
INFECTIVE = meningitis, encephalitis, febrile seizure, sepsis
STRUCTURAL = epilepsy, head trauma/injury, non-epileptic seizures, SOL
CONGENITAL = infantile spasm/West syndrome
OTHER = breath holding attacks, reflex anoxic seizures
How are seizures/unwell child investigated?
BEDSIDE: urinalysis, LP (sent for gram stain + MC&S, PCR, biochemistry)
BLOODS: FBC, U&Es, LFTs, blood glucose, ketones, lactate, toxicology, blood cultures, ABG
IMAGING: CT head, MRI brain
What are sx of raised ICP?
altered LOC, irritability, restlessness, drowsiness, papilloedema, focal neuro signs, prolonged seizures, constant headache (worse on lying down), sudden vomiting w/o nausea, fixed dilated pupils, asymmetrical
CUSHING’S TRIAD = bradycardia, irregular respirations, hypertension
What are contraindications to lumbar puncture?
- clinical or radiological signs of raised ICP
- shock
- after convulsions until stabilised
- coagulation abnormalities
- local superficial infection
- respiratory insufficiency
perform delayed LP in children w/?bacterial meningitis when CIs no longer present
How to identify type of meningitis from LP?
Bacterial = turbid, high polymorphs, high protein, low glucose
Viral = clear, high lymphocytes, normal or high protein, normal or low glucose
TB = turbid/clear/viscous, high lymphocytes, very high protein, very low glucose
What are causes of early onset meningitis?
<72hrs postnatally = GBS, E. Coli (gram -ve rod), Listeria monocytogenes (gram +ve rod)
What are causes of late onset meningitis?
> 72hrs, within 28d postnatally = strep. pneumo (gram +ve coccus), N. meningitides (gram -ve coccus), Staph aureus (gram +ve diplococci clusters).
How should meningoencephalitis be followed up?
- formal audiological assessment: ideally before discharge & <4w of being fit to test (severe profound deafness = urgent assessment for cochlear implants as soon as fit to test)
- paediatrician r/v 4-6w after discharge (consider specific morbidities e.g. hearing loss, orthopaedic, skin, psychosocial, neurological and developmental, renal failure)
- inform GP/health visitor, school nurse: long term sequelae
What are the differences between a simple febrile convulsion and complex FC?
SIMPLE = <15mins, generalised tonic-clonic, no recurrence within 24hrs, no postictal pathology or residual weakness
COMPLEX = >15mins, focal convulsion w/ or w/o secondary generalisation, recurrence within 24hrs even if shorter subsequent seizures, Todd’s paresis may be present (period of paresis of affected limb)
When should a child with febrile seizures be admitted?
- complex febrile seizures
- first febrile seizure
- reduced GCS before seizure
- slow recovery >1hr
- clinical signs of meningism
- focal neurological deficit
- features of septicaemia
- unexplained cause of fever
How does NAI present and how is it investigated and managed?
SX = bruises, burns, fractures, shaken baby syndrome
IX =
- Bedside: full exam, body mapping
- Bloods: FBC, clotting
- Imaging: skeletal survey (repeat at 2w), CT head (if acute), MRI (if non acute), ophthalmology r/v
MX =
- admit + senior review
- contact hospital safeguarding team (may contact social services and/or police)
- child may go home while investigation underway
What is the difference between measles, rubella and roseola infantum?
MEASLES = conjunctivitis, cough, coryza, fever, Koplik spots on buccal mucosa, rash starting at hairline and spreading downwards over 3d
RUBELLA = headache, low grade fever, sore throat, coryza, forchheimer spots on soft palate
ROSEOLA INFANTUM = exanthem subitum = 6-36mths, caused by HHV6, abrupt high fever, rash starting on neck and trunk and then spreading to face and extremities after fever is gone
What is the routine immunisation schedule?
8w =
- diptheria/tetanus/pertussis/polio/Hib/HepB
- MenB
- rotavirus
12w =
- diptheria/tetanus/pertussis/polio/Hib/HepB
- pneumococcal
- rotavirus
16w =
- diptheria/tetanus/pertussis/polio/Hib/HepB
- MenB
1yr old =
- HiB and MenC
- pneumococcal
- MMR
- MenB
What are the diagnostic criteria for Kawasaki’s disease?
Prolonged fever >5d
+4/5 other sx (CRASH)
- conjunctivitis
- rash (hands and feet)
- adenopathy (cervical)
- strawberry tongue
- hands and feet swelling/peeling
How is Kawasaki’s disease managed?
ADMIT
IV IG within 10d + high dose aspirin +/- corticosteroids (alt = infliximab, cyclosporin)
Arrange echo (risk of coronary aneurysm - need for long term warfarin)
Summarise scarlet fever?
Strep A
Sx = sandpaper rash, strawberry tongue, sore throat, rheumatic fever
Ix = throat culture, rapid antigen test
Mx = phenoxymethylpenicillin
Summarise erythema infectiosum?
parvovirus b19
sx = slapped cheeks, coryza
mx = supportive
Summarise hand, foot and mouth disease?
Coxsackie virus A16
sx = small blisters hand and feet and around mouth
mx = supportive
Outline how to investigate abdominal pain?
BEDSIDE = abdo + external genitalia exam, obs, urinalysis, pregnancy test (if relevant)
BLOODS = FBC, U&Es, LFTs, clotting, G&S, XM, amylase, glucose, ketones, lactate, blood cultures
IMAGING = non-contrast CT abdo, abdo USS, AXR, erect CXR
What are causes of a wide anion gap?
WIDE = >30mmol/L
LTKR: Lactate, Toxins, Ketones, Renal
What are causes of a normal anion gap?
NORMAL = 4-12mmol/L
ABCD: Addisons, Bicarb loss (GI or renal loss), Chloride excess, Diuretics (acetozalamide)
What is the diagnostic criteria for DKA?
Hyperglycaemia (BM>11.1)+ metabolic acidosis (pH<7.3/bicarb <15) + ketonaemia (>3)
Severity:
MILD: pH 7.2-7.29, bicarb <15
= 5% dehydration
MOD: pH 7.1-7.19, bicarb <10
= 7% dehydration
SEVERE: pH <7.1, bicarb <5
= 10% dehydration
How is DKA managed?
1 = FLUIDS
- Bolus volume - if in shock 20ml/kg over 15min, if not shocked then 10ml/kg
- Deficit volume - deficit % x 10 x body weight mL/h - added to maintenance over 48h
- Maintenance volume - over 48h, 0.9% NaCl 100/kg for first 10kg, 50/kg for 10-20kg, then 20/kg above 20kg, +40mmol KCl per 1L fluid once UO
2 = INSULIN
- 1-2hrs after fluid therapy
- IV actrapid 0.05-0.1 units/kg/hr
- target rates: BM decreased >3/hr, ketones decreased >0.6 or bicarb increased >0.3
- continue long-acting SC insulin at usual dose and time
- once BM <14 add dextrose (5% if BM 8-14; 10% if BM <8)
- 2mL/kg bolus 10% dextrose if BM < 4 (hypoglycaemia)
3 = MONITORING
- every 1hr = neuro obs, capillary glucose
- every 2-4hr = electrolytes, blood gases, ketones
How is a UTI diagnosed in children and how is it managed?
UTI = pure growth of single organism >10^5 CFU/L
Rx = 3/7 trimethoprim PO
- IV abx if <3mo
- 7-10d course if upper UTI
How are UTIs investigated according if under 6 months?
Single confirmed UTI, responds rapidly to treatment
IX = USS urinary tract
What is an atypical UTI and how is it investigated?
FEATURES = seriously ill, septicaemia, poor urine flow, abdominal or bladder mass, raised serum creatinine, failure to respond to abx within 48hrs, non E. coli organisms
IX =
- USS urinary tract during acute episode
- DMSA scan 4-6mths later if <3yo
- MCUG if age <6mo
What is recurrent UTI and how is it investigated?
FEATURES = 3 or more episodes of cystitis/lower UTI OR 2 or more episodes of UTI if any episode involved upper UTI (renal angle tenderness)
IX =
- USS urinary tract
- DMSA 4-6mo later
- MCUG if <6mo
How is surgical abdomen in children managed generically?
- NBM
- NGT on free drainage
- IV fluids
- IV analgesia (avoid opioids if ?obstruction)
- IV Abx
- liaise w/surgical SpR
- liaise w/CEPOD (dedicated theatre lists for emergencies)
