Paediatric Emergencies Flashcards
Which child should be moved to the resuscitation area for urgent management in accident and emergency?
A. A miserable 2 year old with a fever and vomiting temperature of 38.5°C, heart rate of 150, respiratory rate 42, capillary refill time 2–3 seconds who is alert and clinging on to his father and has just been given paracetamol and started on a fluid challenge with oral rehydration salts 5 minutes ago by the triage nurse
B. A quiet 4 year old brought in with an asthma attack who is sitting upright with a respiratory rate of 50, heart rate of 162, capillary refill time of 3 seconds, subcostal recessions and poor air entry on chest auscultation following a salbutamol nebulizer
C. An 8 year old, known diabetic, brought in vomiting with her glucose reader saying HI. She is able to tell you her history and has a heart rate of 120, respiratory rate of 25, capillary refill time of
B. A quiet 4 year old brought in with an asthma attack who is sitting upright with a respiratory rate of 50, heart rate of 162, capillary refill time of 3 seconds, subcostal recessions and poor air entry on chest auscultation following a salbutamol nebulizer
1 B Child (B) is the sickest here and should be moved to the resuscitation area with a dedicated nurse and doctor to manage her. She is having a severe asthma attack: she is tachycardic and tachypnoeic with circulatory compromise, a prolonged capillary refill time and she has not responded to initial management. Child (A) is unwell with tachycardia, tachypnoea and a slightly prolonged capillary refill time but is pyrexic and has just been given treatment. He should be reviewed in 30 minutes to see that his parameters are improved. Child (C) is at risk of diabetic ketoacidosis and should be assessed quickly with a blood gas but she remains alert and orientated with no evidence of circulatory compromise so she is stable enough to remain in general paediatric accident and emergency, but it important to be aware that these patients can get very sick. Patient (D) has a non-blanching rash in the superior vena caval distribution and has normal observations. This is unlikely to be meningococcal sepsis and more likely to be a petechial rash related to the pressure of coughing; however any non-blanching rash should be reviewed by a senior clinician and should be isolated in a side room in accident and emergency. Patient (E) also has the potential to become quite sick but she is currently stable and may need privacy for talks with the mental health team once she is medically cleared; she would benefit from a side room if it is free.
A 4-year-old child has been losing weight recently and has been vomiting for the past 24 hours, unable to eat anything. His mother has brought him into accident and emergency out of concern as he seems confused. The triage nurse has taken him to the resuscitation room and asked for your help. On examination he is drowsy, has a heart rate of 150, respiratory rate of 60 and a central capillary refill of 5 seconds. He has subcostal recessions and good air entry bilaterally with no added sounds. He moans when you examine his abdomen but there are no masses. You put in a canula and take bloods. The venous blood gas shows:
pH 7.12 PCO2 2.3 kPa
PO2 6.7 kPa
HCO3–15.3 mmol/L
BE –8.6
Glucose 32.4 mmol/L
What is the most likely diagnosis and what is the first management step?
A. Diabetic ketoacidosis, start an insulin infusion
B. Diabetic ketoacidosis, give a fluid bolus
C. Pneumonia, start IV co-amoxiclav
D. Ruptured appendix, give a fluid bolus and book the emergency operating theatre
E. Gastroenteritis with severe dehydration, give a fluid bolus
B. Diabetic ketoacidosis, give a fluid bolus
2 B This child has new-onset, type 1 diabetes; he has been losing weight and the blood gas shows a very high glucose and a metabolic acidosis (remember that in paediatrics, arterial gases are rarely used, and that a venous PO2 will be low; this gas does not show respiratory failure.) The chest is clear on examination and the gas does not show a respiratory acidosis; therefore this is not pneumonia (C). The first management for him is rehydration (B). Only after an hour of rehydration should he be started on intravenous insulin. It is important to correct his dehydration and hyperglycaemia slowly over 2 days due to the risk of brainstem demylination with rapid shifts in salts in the cerebrospinal fluid; therefore (A) is incorrect. Appendicitis (D) or gastroenteritis (E) would be reasonable if the glucose were normal. In the context of a tachycardia with prolonged capillary refill, a patient should be given a fluid bolus and reassessed. Patients should be stabilized before going to the operating theatre.
An 8 year old known asthmatic is brought into accident and emergency by ambulance as a ‘blue call’. He has been unwell with an upper respiratory tract infection for the past 2 days. For the past 24 hours his parents have given him 10 puffs of salbutamol every 4 hours, his last dose being 90 minutes ago. The ambulance staff have given him a nebulizer but he remains agitated with a heart rate of 155, respiratory rate of 44 and sub/intercostal recessions and on auscultation there is little air movement heard bilaterally. Saturations in air are 85 per cent. He is started on ‘back to back’ nebulizers with high flow oxygen. How severe is his asthma exacerbation and what other bedside test would support this?
A. Moderate, venous blood pH 4.4, gas PCO2 = 3.1 kPa
B. Severe, peak flow
D. Life-threatening, peak flow
The accident and emergency triage nurse asks you to look at a 3-year-old child with a short history of waking up this morning unwell with a cough and fever. She looks unwell, heart rate is 165, respiratory rate 56, saturations of 96 per cent in air, temperature of 39.3°C and central capillary refill of 4 seconds. She has a mild headache but no photophobia or neck stiffness and you notice a faint macular rash on her torso and wonder if one spot is non-blanching. You ask the triage nurse to move her to the resuscitation area and call your senior to review her. Fifteen minutes later your senior arrives and the spot you saw on the abdomen is now non-blanching and there is another spot on her knee. What are the three most important things to give her immediately?
A. High flow oxygen, IV fluid bolus, IV ceftriaxone
B. IV fluid bolus, IV ceftriaxone, IV methylprednisolone
C. High flow oxygen, IV ceftriaxone, IV fresh frozen plasma
D. IV fluid bolus, IV ceftriaxone, IV fresh frozen plasma
E. High flow oxygen, IV ceftriaxone, IV methylprednisolone
A. High flow oxygen, IV fluid bolus, IV ceftriaxone
4 AThe correct answer is (A): she has presented with a classic presentation of meningococcal sepsis. Do not forget to always give sick children oxygen; if the mask makes them more distressed a minimum of wafted high flow O2 may suffice. The child has a prolonged capillary refill and is tachycardic; she should have a fluid bolus (20 mL/kg) and be reassessed. As soon as intravenous or intraosseous access is obtained she should be given IV ceftriaxone, but only after the blood culture has been taken. (B) and (E) are incorrect as there is no mention of the child having meningitis. Currently there is no formal consensus as to whether steroids should be routinely used but administration before or with the first dose of antibiotics has been shown to be beneficial for some types of bacterial meningitis. (C) and (D) are incorrect as you do not yet have clotting results. She will likely need fresh frozen plasma to correct her disseminated intravascular coagulation which is evidenced by the forming non-blanching rash.
A 9-year-old boy is brought in by ambulance having been hit by a car while playing football in the street. You have been assigned to do the primary survey in resus when the ambulance arrives. The patient is receiving oxygen, crying for his mummy and holding his right arm, but able to move over from the stretcher to the bed when asked. Which is the correct examination procedure?
A. The trachea is deviated to the right. On auscultation you hear decreased air entry on the left. Percussion note is hyper-resonant on the left. He is tachycardic and his heart sounds are muffled, heard loudest at the right lower sternal edge. You ask for a left-sided thoracocentesis.
B. You introduce yourself and tell him that you will be gentle but need to check that he is okay. You see his left wrist is deformed and swollen and check the fingers which are cool and note the capillary refill is 4 seconds. He is able to feel you touching him and moans when you examine the wrist. You call for an x-ray to assess the probable fracture in the wrist.
C. You introduce yourself and tell him that you will be gentle but need to check that he is okay. You listen for equal air entry and think there is decreased air entry on the left but there is air entry on the right. He is tachypnoeic and has a pulse which is tachycardic. His capillary refill is 4 seconds. You expose his abdomen and notice bruising and grazes to the left side. He moans as you palpate in the left upper quandrant and has guarding. You ask for an IV canula or intraosseous needle and a 20 mL/kg fluid bolus while organizing an urgent CT chest and abdomen.
D. You introduce yourself and tell him that you will be gentle but need to check that he is okay. He is tachypnoeic. The trachea is deviated to the right. On auscultation you hear decreased air entry on the left. Percussion note is hyper-resonant on the left. He is tachycardic and his heart sounds are muffled, heard loudest at the right lower sternal edge. You ask for a left-sided thoracocentesis.
E. You listen for equal air entry and think there is decreased air entry on the left but there is air entry on the right. He is tachypnoeic and has a pulse which is tachycardic. His capillary refill is 4 seconds. You expose his abdomen and notice bruising and grazes to the left side. He moans as you palpate in the left upper quandrant and has guarding. You ask for an IV canula or intraosseous needle and a 20 mL/kg fluid bolus while organizing an urgent CT chest and abdomen.
D. You introduce yourself and tell him that you will be gentle but need to check that he is okay. He is tachypnoeic. The trachea is deviated to the right. On auscultation you hear decreased air entry on the left. Percussion note is hyper-resonant on the left. He is tachycardic and his heart sounds are muffled, heard loudest at the right lower sternal edge. You ask for a left-sided thoracocentesis.
5 DAnswer (D) is correct, you introduce yourself to the patient and follow the ABCD approach: A is for Airway, he is crying therefore it is patent. B is for Breathing; you find evidence of a pneumothorax therefore you do not proceed further in your assessment until B is addressed with a needle thoracocentesis decompression. (A) is incorrect as you have not introduced yourself which is very important in gaining patient trust and examination cooperation. (B) is examination of D = disability, you have skipped the ABC and missed several life-threatening conditions. (C) is incorrect as you failed to respond to a problem in (B) despite noticing signs of a tension pneumothorax. (E) is incorrect as you failed to introduce yourself and to address the pneumothorax noted in assessing breathing.
A 6-year-old boy with a history of anaphylaxis to peanuts is brought in by ambulance unconscious. He was attending a children’s birthday party. His mother says there was a bowl full of candy and he may have eaten a Snickers bar but she is not sure and she did not have his EpiPen with her. His face and lips are swollen and erythematous, he is still breathing but weakly and there is wheeze. His pulse is tachycardic and thready. Which type of shock is this?
A. Hypovolaemic
B. Distributive
C. Septic
D. Cardiac
E. Obstructive
B. Distributive
6 B Shock is inadequate perfusion of tissues which is insufficient to meet cellular metabolic needs. This child presents with anaphylaxis, but did not have early intramuscular adrenaline to prevent the capillary leak of fluid into his airway tissues. Due to oedema his airway is closing off. The rapid shifts in fluid to the interstitium results in intravascular hypovolaemia and shock. This is distributive shock (B). Hypovolaemic shock (A) is due to haemorrhage or dehydration, and the patient would be pale, cool and poorly perfused. In septic shock (C) you would expect a fever and history suggesting infection. In cardiac shock (D) the heart is unable to meet the circulatory demands of the body, resulting in shock. There is chest pain or other cardiac symptoms and this is rare in childhood outside of congenital heart or Kawasaki’s disease. Lastly, obstructive shock (E) is due to blockage of blood flow from the heart, either due to cardiac tamponade, fluid in the pericardial sac compressing the heart or tension pneumothorax.
A 13 month old is brought in having had a blue floppy episode at home lasting 1 minute. While you are taking a history from the mother, you notice the baby has gone blue again and seems to be unconscious in her arms. You call for help and place the baby on the examination table. There is no obvious work of breathing. The nurses bring the crash trolley and give you a bag valve mask, which they are connecting to the oxygen. You give two inflation breaths but do not see the chest rise. You reposition the air way and this time the breaths go in. You feel for a pulse and there is none. When asked to do CPR the nurse asks for direction on how many breaths and compressions you both need to do.
A. Two inflation breaths per 30 compressions
B. Two inflation breaths per 15 compressions
C. Continuous inflation breaths about 10–12 per minute and compressions 100–120 per minute
D. One inflation breath per five compressions
E. Two inflation breaths per five compressions
B. Two inflation breaths per 15 compressions
7 B As of November 2010 the paediatric advanced life support guidelines for CPR recommend two inflation breaths per 15 chest compressions (B). This is different from the adult guidelines of two breaths to 30 compressions (A). Answer (C) is correct once the child is intubated but in this scenario, the child is not. Answer (D) is the old neonatal guidelines and is no longer used. Answer (E) is not used at all.
A 10-year-old child is brought in by ambulance with seizure activity. His mother reports it starting 30 minutes ago in his right arm and quickly became generalized tonic clonic jerking. She gave him his buccal midazolam after the first 5 minutes and called an ambulance when he did not respond after another 5 minutes. The ambulance crew gave him rectal diazepam on arrival at 15 minutes into the seizure. He is receiving high flow oxygen via a face mask and continues to convulse. The mother tells you that he was weaned from his long-term seizure medication, phenytoin, 2 weeks ago and that he has had a cold for the past 2 days. What is the next step in management?
A. Gain intravenous or intraosseous access and administer lorazepam
B. Gain intravenous or intraosseous access and administer ceftriaxone
C. Repeat the rectal diazepam
D. Gain intravenous or intraosseous access and start a phenytoin infusion
E. Gain intravenous or intraosseous access and start a phenobarbital infusion
D. Gain intravenous or intraosseous access and start a phenytoin infusion
8 DThe child has now had two doses of barbiturate and management should proceed to the next step in management of status epilepticus (seizure lasting greater than 30 minutes): IV phenytoin (D). Due to the risk of respiratory depression further doses of barbituates ((A) or (C)) should be avoided. It should be noted that many text books still recommend the use of per rectum peraldehyde if two doses of barbituates fail; however this is now not routinely used in management of status epilepticus due to significant rates of drug errors such as IV rather than rectal administration. If his epilepsy was currently managed by phenytoin he should be given intravenous phenobarbital (E) but he was recently taken off of it. Intravenous ceftriaxone (B) may be indicated in a situation of status epilepticus associated with fever as encephalitis may present with seizures, but it is not the next step in management.
A 3-year-old boy is brought in by ambulance fitting. You are assigned to get the history from the father. Harry is normally fit and well with no significant past medical history or allergies. He is up to date with his immunizations and has been growing and developing normally. His behaviour has been difficult for the past 2 weeks since the birth of his little sister. Mum has been unwell as she developed HELLP syndrome and was in hospital for a week following the delivery. Yesterday, he was quite unwell with a tummy bug, vomiting and had black diarrhoea. That evening they found a mess he had made in the bathroom with all of his mum’s things strewn over the floor including her tablets from the hospital. By that time, Harry was getting better so they did not think anything of it. Today he has been acting strangely and has been difficult to understand, he then became lethargic at about 4 pm and started fitting 15 minutes ago. What is the most likely diagnosis?
A. Paracetamol overdose
B. Aspirin overdose
C. Tricyclic antidepressant overdose
D. Bleach intoxication
E. Iron overdose
E. Iron overdose
9 E The answer is iron overdose (E) which classically is a two phase illness with early vomiting and diarrhoea due to gastric irritation and may present with haematemesis or malaena (the black diarrhoea). There is a period up to 24 hours of improvement and then deterioration with liver failure, drowsiness and coma. The liver failure can produce hypoglycaemia and seizures. The mother has recently had HELLP syndrome, liver failure, thrombocytopenia and hypertension in pregnancy. These patients often have significant haemorrhage and go home on iron supplements. Paracetamol overdose (A) in young children is often not in large doses due to the tablets being difficult to swallow; it may present with gastric irritation or a history that the child took some tablets, liver failure develops on day 3–5, our case presented on day 2 and you would not expect malaena from paracetamol intoxication. Tricyclic antidepressant (C) overdose would present much earlier than 2 days, with tachycardia, anticholinergic symptoms (dry mouth, blurred vision, agitation). Patients become shocked with seizures or coma and develop severe metabolic acidosis and this is one of the few indications for giving intravenous bicarbonate. Bleach intoxication (D) should be thought of as he was in the bathroom playing on his own; however problems are rare as the bleach does not taste nice and typically there will only be localized lesions where the bleach contacted the mucous membranes.
A 6-year-old boy with a history of asthma and eczema is brought in to accident and emergency from a local restaurant. He is on high flow facial oxygen with significant facial oedema and generalized erythema. On auscultation there is widespread wheeze for which the ambulance crew gave a salbutamol nebulizer. What is the next step in management?
A. Insert an IV line and give 10 mg slow intravenous antihistamine
B. Insert an IV line and give 100 mg slow intravenous hydrocortisone
C. Insert an IV line and give 200 μg of 1:10 000 intravenous adrenaline
D. Give intramuscular 1:1000 adrenaline, 250 μg
E. Repeat the salbutamol nebulizer and call for an anaesthetist for intubation
D. Give intramuscular 1:1000 adrenaline, 250 μg
10 D All of the answers are correct except for (C) which is the dose of adrenaline for cardiac arrest. (D) is the best answer as it is the most important life-saving treatment; IM adrenaline will work to reduce the capillary leak which is producing airway oedema. Once the fluid has shifted out of the vascular space, there is no way to rapidly move it out of the tissues; therefore the key first management of anaphylaxis is to administer IM adrenaline. In reality you would put out an emergency call for an anaesthetist (E) to manage the rapidly closing airway, give further salbutamol nebulizers and gain intravenous access to give hydrocortisone and antihistamine. Give (A) to block the histamine release which is driving the capillary leak and (B) to reduce general inflammation and aim to prevent the late type IV hypersensitivity. It is important not to forget about delayed type IV hypersensitivity; these children should be observed and sent home with two further doses of prednisolone for the next 2 days to cover this.
