Paediatric Emergencies Flashcards

1
Q

What is sepsis? Furthermore, what is severe sepsis and septic shock?

A

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

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2
Q

What are signs of red flag sepsis? What does this mean?

A

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
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3
Q

What are the common causative organisms of sepsis (think early onset neonatal sepsis vs late and older children)?

A

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
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4
Q

What are the risk factors for neonatal sepsis?

A

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

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5
Q

How would you Ix + manage a patient with suspected sepsis?

A

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
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6
Q

What is meningitis and how may it present?

A

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

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7
Q

What are the Kernig’s and Brudzinski’s sign in meningitis?

A

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

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8
Q

What is Cushings triad for raised ICP?

A

Cushings triad of raised ICP = high BP, low HR, irregular RR

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9
Q

How would you investigate a child with suspected meningitis?

A

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)
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10
Q

How would you manage a child with bacterial meningitis?

A

(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)
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11
Q

How would you treat viral meningitis? What are the common pathogens? What would the LP results show?

A

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
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12
Q

What is encephalitis and what may it be caused by? What causative organisms are the most common?

A

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)
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13
Q

What may someone with encephalitis present with?

A
  • altered consciousness
  • seizures
  • fever
  • behavioural change
  • rash from viral infection
  • similar to meningitis so often treatment is initiated for both DDx
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14
Q

How would you investigate a patient with suspected encephalitis?

A

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
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15
Q

How would you manage a patient with encephalitis?

A

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
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16
Q

DAPSICAMP - Anaphylaxis

A

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

17
Q

What are the neonatal resuscitation guidelines?

A

NRS:

  1. Dry baby - note/start time
  2. Within 30s - assess tone, RR, HR (femoral, brachial) and colour (consider SpO2 + ECG monitoring)
  3. 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
  4. Chest moves, HR slow (<60 bpm) - ventilate for 30s and give compressions + ventilation (rate 3:1)
  5. 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)
18
Q

If a baby has had tracheal intubation but their HR doesn’t increase/no good chest movement, what should you consider?

A

Consider DOPE:

  • Displaced tube
  • Obstructed tube
  • Patient factors - tracheal obstruction, lung disorders, shock from blood loss, perinatal asphyxia
  • Equipment failure
19
Q

What is paediatric BLS?

A

BLS:

  1. Check DRS
  2. Shout for help
  3. Open airway
  4. Look listen feel for breathing
  5. 5 rescue breaths
  6. Check for signs of circulation (brachial, radial pulse)
  7. 15 chest compressions, 2 rescue breaths
20
Q

Explain some of the red and amber warning signs for children with fever? What does red, amber and green indicate for Mx/next steps?

A

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

21
Q

What is the difference between a child in need plan and a child protection plan?

A

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

22
Q

What is the triad of symptoms for shaken baby syndrome?

A

(1) Retinal haemorrhages
(2) CT = brain swelling / encephalopathy
(3) CT = subdural haematoma

23
Q

What is the difference between Fraser guidelines and Gillick competency?

A

Gillick refers to the ability for a child to consent to treatment

Fraser specifically refers to the contraception consent and prescription