Paediatric Emergencies Flashcards
What is sepsis? Furthermore, what is severe sepsis and septic shock?
Sepsis is the dysregulated immune response to infection (SIRS in the presence of infection)
SIRS = 2/+ of the following where 1 MUST be abnormal WCC (low/high or >10% immature cells) OR abnormal temperature (<36 or >38.5), and abnormal HR and raised RR
severe sepsis - SIRS + CV dysfunction, RDS or dysfunction of 2/+ organs
septic shock - sepsis with CV dysfunction persisting after 40ml/kg resus boluses in 1h
What are signs of red flag sepsis? What does this mean?
If present, immediate SEPSIS 6 pathway initiation:
- Hypotension
- V/P/U on AVPU score
- Cap refil>5s
- Oxygen required for SpO2 >92%
- Blood lactate >2mmol/L
- Pale/mottled or non-blanching purpuric rash
- RR >60 or >5 below normal OR grunting
- Abnormal behaviour - V dry nappies, weak high pitched continuous cry, decreased activity/reduced response to social cues
What are the common causative organisms of sepsis (think early onset neonatal sepsis vs late and older children)?
Early onset neonatal sepsis (<24h)
- GBS
- E.Coli
- Listeria monocytogenes
Late onset neonatal sepsis (>72h)
- CoNS (coagulate negative staph i.e. staph epidermidis)
Older children: - Neisseria meningitides - Staph aureus (CoPositive) [both most common 6-65y^^) - Strep pneumonia - Non-pyogenic streptococci
What are the risk factors for neonatal sepsis?
note: sepsis may cause neonatal jaundice!
RFs:
- PROM/PPROM [1]
- Maternal GBS infection [1]
- Premature [1]
- Chorioamnionitis (fever during labour) [1]
- Twin with neonatal sepsis [2]
If scores >2 then Abx given till negative blood cultures for 36h
How would you Ix + manage a patient with suspected sepsis?
Ix:
- clinical suspicion (low threshold due to rapid deterioration)
- IV access + bloods (venous gas - includes glucose+lactate, cultures, FBC, CRP, and U&Es/Cr, Clotting if possible)
- LP in <1mo, 1-3mo who look unwell OR have WCC<5/>15
- Other: urine dip, CXR if this suspected aetiology
Mx:
- Paediatric SEPSIS 6 within 1h and transfer to acute setting with hourly reviewal and continuous monitoring
- Senior reviewal
- IV Fluid resus (20ml/kg bolus NS over 5-10 mins)
- Abx within 1h following local guidelines:
if meningococcal sepsis
- IM Benzylpenicillin in community
- IV Cefotaxime/Ceftriaxone in hospital
if other:
- EONS - IV Cefotaxime + amikacin/ampicillin (to cover listeria also)
- LONS - IV Meropenem + amikacin/ampicillin
What is meningitis and how may it present?
Life-threatening/serious inflammation of the meninges which may be either viral or bacterial.
Presents with:
- fever
- headache
- photophobia
- neck stiffness
- lethargy, drowsiness, altered consciousness, seizures
- non-blanching rash (meningococcal septicaemia)
- opisthotonos (hyperextension of neck and back)
- bulging fontanelle
- high HR to compensate brain ischaemia but then lowers
- vomiting
What are the Kernig’s and Brudzinski’s sign in meningitis?
Kernigs - pain on straightening the leg/knee extension when the hip is flexed at 90 degrees
Brudzinski’s - supine neck flexion causes reflex hip flexion
What is Cushings triad for raised ICP?
Cushings triad of raised ICP = high BP, low HR, irregular RR
How would you investigate a child with suspected meningitis?
Ix:
- lumbar puncture within 1h (1st) but NOT if meningococcal meningitis
- blood cultures within 1h
- other bloods - FBC, CRP, U&Es, glucose, LFTs
- venous blood gas
- coagulation screen (PT, INR etc) as coagulopathy is common in severe infections)
- further immunological analysis e.g. complement deficiency if had multiple meningitis episodes (>1)
How would you manage a child with bacterial meningitis?
(LP/BC will show low glucose, high protein, high neutrophils/bacterial infection)
Mx: - admit and follow sepsis 6 pathway - IV Abx treatment (<3m = cefotaxime + ampicillin; >3m = IV ceftriaxone and also if seen in community first, give IM Benzylpenicillin OR if allergic then moxifloxacin+vancomycin) IV ceftriaxone for: --> 10 days if HiB --> 14 days if Strep. Pneumoniae --> 7 days if N. meningitidis - IV Dexamethasone if: purulent CSF, bacteria gram stain, >1m and HiB infection, NOT meningococcal, raised CSF WCC + protein >1g/L, WBC>1000/uL - Mannitol to reduce ICP - IV Maintenance fluids 0.9% NS - notify HPU - review patient in 4-6w after discharge to discuss any long-term complications e.g. hearing loss (audiological assessment), neurological issues, renal failure, skin (e.g. purpura fulminans is a severe complication causing skin necrosis from DIC) - treat contacts (ciprofloxacin)
How would you treat viral meningitis? What are the common pathogens? What would the LP results show?
LP will show high lymphocytes, normal glucose and high protein
Most commonly due to cocksackie B, echovirus
- Discharge home after exclusion of bacterial cause and supportive therapy e.g. fluids
- Safety net
What is encephalitis and what may it be caused by? What causative organisms are the most common?
Encephalitis is inflammation of the brain parenchyma
Aetiology:
- Direct invasion of cerebellum by neurotoxic viruses e.g. HSV
- Post-infectious encephalopathy of delayed brain swelling following neuroimmunological response to antigen
- Slow virus infection e.g. HIV or subacute sclerosing pan-encephalitis post measles infection:
- -> in the UK most common are enterovirus, respiratory viruses e.g. influenza and HERPES [HSV] (70% mortality if untreated), VZV, HHV-6 (rare others = ticks, mosquitos=japanese encephalitis, bacteria/fungus)
What may someone with encephalitis present with?
- altered consciousness
- seizures
- fever
- behavioural change
- rash from viral infection
- similar to meningitis so often treatment is initiated for both DDx
How would you investigate a patient with suspected encephalitis?
Same as meningitis:
- LP [CI include signs of raised ICP, thrombocytopenia or coagulopathy, focal neurological signs, meningococcal meningitis]
- MRI - may show hyper intense lesions, oedema, BBB breakdown
- Bloods (Cultures, FBC, Glucose/Gas, U&Es, CRP, LFTs)
- PCR for viruses
How would you manage a patient with encephalitis?
Mx:
- IV acyclovir high dose for 3w (HSV is rare but deadly so treat empirically)
- dose = 500mg/m2 SA for every 8h for 21 days in simplex encephalitis
- IV administration of acyclovir with NaCl (5mg/ml) and water (25mg/ml)
- add in ganciclovir and Foscarnet in CMV and use either acyclovir or ganciclovir in VZV
- supportive care - fluids, ventilation/oxygen
DAPSICAMP - Anaphylaxis
Type 1 hypersensitivity reaction = antigen cross-linking with IgE membrane-bound antibody of mast cell or basophil
Incidence = 1: 20,000 person/years; 1 in 1,000 are fatal (mostly in adolescents when concerning food)
NOTE: In children, 85% due to food allergy (and most are in those <5yo)
Signs & symptoms:
- > Airway - swelling, hoarseness, stridor
- > Breathing - high RR, wheeze, cyanosis, SpO2 <92%
- > Circulation - pale, clammy, low BP, drowsy, coma
- > Skin - urticaria/angioedema
Management:
o ABCDE approach and call for help
BLS might be needed if unresponsive/not breathing
o IM Adrenaline (1: 1,000) – dose as per guidelines/weight
-> Given in thigh
-> Assess response after 5 minutes and repeat if needed
Monitoring and additional treatment:
Establish airway + high-flow O2
IV fluids (20mL/kg crystalloids)
IV Chlorpheniramine, 10mg (IM or slow IV)
IV Hydrocortisone, 200mg (IM or slow IV)
Salbutamol (if wheeze)
o Hereditary angioedema (C1 esterase deficiency) / AD:
S/S: recurrent facial swelling & abdominal pain
What are the neonatal resuscitation guidelines?
NRS:
- Dry baby - note/start time
- Within 30s - assess tone, RR, HR (femoral, brachial) and colour (consider SpO2 + ECG monitoring)
- Within 60s - if not breathing then open airway and give 5 inflation breaths
a) ) Reassess - if no increase in HR, look for chest movement, if no chest movement then recheck head position, suction airway and other airway manoeuvres and repeat 5 inflation breaths.
b) ) Repeat and reassess until chest movement seen - Chest moves, HR slow (<60 bpm) - ventilate for 30s and give compressions + ventilation (rate 3:1)
- Reassess every 30s - if HR undetectable/slow (60 bpm) then consider IV access and drugs –> 1:10,000 adrenaline, fluid resus with NaCl, dextrose and bicarb for metabolic acidosis
Debrief and update parents
APGAR score
- Used at 1 and 5 mins after delivery (and every 5m if needed)
- > 7 is normal
- Appearance, pulse, grimace, activity, respiratory effort (0-2)
If a baby has had tracheal intubation but their HR doesn’t increase/no good chest movement, what should you consider?
Consider DOPE:
- Displaced tube
- Obstructed tube
- Patient factors - tracheal obstruction, lung disorders, shock from blood loss, perinatal asphyxia
- Equipment failure
What is paediatric BLS?
BLS:
- Check DRS
- Shout for help
- Open airway
- Look listen feel for breathing
- 5 rescue breaths
- Check for signs of circulation (brachial, radial pulse)
- 15 chest compressions, 2 rescue breaths
Explain some of the red and amber warning signs for children with fever? What does red, amber and green indicate for Mx/next steps?
Think colour, respiratory, activity, circulation+hydration and other
Red:
- C: pale/mottled/ashen/blue
- R: grunting, tachypnoea >60, moderate-severe chest indrawing, apnoeas
- A: no response to social cues, appears ill to HCP, weak-high pitched continuous cry, doesn’t wake/stay roused
- CH: reduced skin turgor
- O: <3m with fever of 38/+, non blanching rash, bulging fontanelle, neck stiffness, seizures
Amber:
- C: pallor reported by parent/carer
- R: nasal flaring, RR >50 if 6-12m or >40 if 12m+, sats 95%/ 160 if <12m, >150 if 1-2y and >140 if 2-5y, CRT >3s, dry mucous membranes, reduced urine output, poor feeding in infants
- O: T>39 at 3-6m, fever for 5d/+, riggers, swelling of a limb or joint and non-weight bearing limb
Mx:
Green = manage at home with appropriate care, advice and safety netting
Amber = safety net (information, f/u or other HCP liaison) or refer to paediatric specialist for further assessment
Red = refer urgently to paediatrics
What is the difference between a child in need plan and a child protection plan?
Child in need plan = a plan made to give children extra support for health, safety ± developmental issues
Child protection plan = a plan made to protect children thought to be at risk of significant harm
What is the triad of symptoms for shaken baby syndrome?
(1) Retinal haemorrhages
(2) CT = brain swelling / encephalopathy
(3) CT = subdural haematoma
What is the difference between Fraser guidelines and Gillick competency?
Gillick refers to the ability for a child to consent to treatment
Fraser specifically refers to the contraception consent and prescription
