paediatric emergencies Flashcards
presenation of acute epiglottitis
syx of stridor/drooling
fever in 3-7yo becomes toxic within a few hours
cause of acute epiglottitis
haemophilus influenzae B
-found in throat and blood culutes
what not to do regarding mangement of acute epiglottits
DO NOT try and visualise epiglottis nor cause child distress (cannulation)
both can precipitate a respiratory arrest
management of acute epiglottits 4
move to nearest ITU
intubation of airway be experieinced anaethetis is likely needed
humified air/o2
cefotaxime IV
differentials for acute epiglottitis 3
foreign body
retropharyngeal abscess
diptheria
presenation of acute croup 4
inspiratory stridor usually preceded by a few days of coryzal syx
mild fever
contitutional upset
wheeze common
-can appear like epiglottitis
management of acute croup 2
humidy air/o2
no ABx
dexamethasone oral
rarely intubation
how can causes of acute respiratory failure be classified 4
central
airway
parenchymal
chest wall
regarding causes of acute respiratory failure
central causes 4
head injury
drugs
convulsion s
infection
regarding acute respiratory failure
airway causes 2
acute epiglottitis
foreign body
regarding acute respiratory failure
parenchymal causes 3
pneumonia
bronchiolitis
asthma
regarding acute respiratory failure
cehst wall acuses 3
polio
trauma
presenation of acute respiratory failure 4
restless
agitaed
cyanosis
silent chest no moving sufficeinct air
blood gasses in acute respiratory failure
low PaCO2 <8kPa
and/or rising CO2
basic management of acute respiratory failure 4
secure airway
bag and mask
intubate
assist ventilation
deal with primary causes
presentation of acute bronchiolitis 4
cold followed by (3-5days) later porgressive cough, wheeze, difficulty in feeding
signs as for asthma
fine inspiratory crepitation (in infants 6wks to 6 mnths) due to RSV
presentation of acute bronchiolitis 4
cold followed by (3-5days) later porgressive cough, wheeze, difficulty in feeding
signs as for asthma
fine inspiratory crepitation (in infants 6wks to 6 mnths) due to RSV
presentation of acute bronchiolitis 4
cold followed by (3-5days) later porgressive cough, wheeze, difficulty in feeding
signs as for asthma
fine inspiratory crepitation (in infants 6wks to 6 mnths) due to RSV
management of acute bronchiolitis 4
oxygen
suction of secretions
tube feeding or IV fluids if unable to feed orally
ABx given accoridng to age and severity of illness if bacterial infection suspected
\
*note 1/3 later develop asthma
presenation of acute asthma 7
from 1 year of age
expiratory wheeze
difficulty speaking
head extened
nostrils flared
chest increased AP diameter
accessory msucels working
rapid pulse
may have pulsus paradoxus
cyanosisin air
management of acute asthma 5
nebuliased salbutamol
oxygen if hypoxic/cyanosed or via nebuliser
theophylline IV
conisdr continous IV fluids, theophylline and hydrocort if inadequate response
-introduce oral pred and bronchodilators as sosn as practicle
ABx only if good evidence of infection
-monitor pulse, resp, CXR and blood gasses in severe or deteriroating episoders
what type of pneumonia is more common in children
bronchopneumonia commoner than lobar pneumonia
-espically in pre-school child
hwo can causes of pneumonia be split
primary -bacterial or viral
or
secondary
secondary causes of pneumonia 3
post measles
whooping cough
milk inhalation
how do babies with pneumonia present 5
v ill
grey
cyanosed
resp rate and effort increased
can have febrile convulsions
what can lobar pneumonia in older children mimic
acute appendicitis
investgiations for pneumonia 5
CXR
Hb and WBC
throat swab
blood cultures
mantoux
what investigations can be indicated in recurrent pneumonia 3
sweat test
look for foreign body
immune deficeincy
management of pneuonai 5
suck out secretions from airway
give physio
O2
NG or IV feed
ABx
abx used for paeds pneumonia 3
*-what if staph pneumonia suspected 11
<5 - (highly likely strep pneumoniae)
- amoxicillin
≥5 or likely mycoplasma or chlamydia
= azithromycin
pneumonia compication influenxa - co-amox
*-fluclox
important syx of cardiac failure in children 3
feeding prblems
breathlessness on feeding
sweating
other syx of cardiac failure in children 4
lethargy
failure to thirve
recent excessive weight gain or oedema
blue attacks
what can often precipitate or exacerbate cardiac failure in children
intercurrent illness eg pneumonia
signs of cardiac failure in children 2
rapid pulse and respiration
HSM
investigations for cardiac failure in children 6
CXR
ECG
Hb
WBC
UnEs
bacteriology
management of cardiac failure in children 6
diuretic- furosemide
digoxin
oxygen
morphine for agitation
position
treat preciptiting event (ie infection, anaemia)
what needs to be considered with diuretic use in cardiac failure in children
chekc UnEs
-conisder potassium supplements
-unless spiro added
point about dignoxin use in cardiac failure in children 3
can be omitted or relatively CI eg fallots tetrology
oral admision
-maintenance is 1/4 of loading dose
CHECK pulse rate before each dose
-if slow or irregular -OMIT
position of cardiac failure in children
sitting or on an incline , head up
what needs to be monitored in cardiac failure in children 4
weight
pulse
resp rate
liver size
rate of compression in a child
1 breath to 5 compressions at 80-100 compressions per minute
drugs for cardiac arrest
ABCDE
adrenaline/atropine/antidote (eg naloxone in newborn)
bicarb
calcium salts
dextrose
ECG
immediate action of burns and scalds at home 3
strip off afffected clothing
-as retains hot liqiud
if small immerse in cold running water
or ad ice to basin of cold water until cool
cover area in clean dry sheet, towel or dressing
hospital assement of burns and scalds
airway -respiratroy tract burn likely if soot in nostils or wheezy
IV access
appropriate analgesia IV morphine
plasma expanders if >10% of surface area affected
weigh patient
Hb check for early haemoconcentration
monitor urine output, bood and urine bioche
what plasma expanders are used in burns and scalds 3
*why use pplasma expanders
ONLY IF >10% SA AFFECTED
colloid (plasma/plasma portein fraction)
ringers solution
if full thicknesss burn/scald-blood
*-prevent shock , renal failure
classificying surface area of burns and scalds in children
cant use ruleof 9s
charts available in ED or size of childs palm is roughly 1%
classification of burn depth 4
superficial
superficil dermal
deep dermal
full thickness
appearnace of superficial burns
essentially like sunburn
no blisters
appearance of superficial dermal burns
good blood supply
pink
blistered
presentation of deep dermal burns
altered sensation but not painless
blisters may be present
ofteb well demarcated w a speckled appearance
presenation of full thickness burns
painless
white/brown
dry
when shoudl burns be refered 3
all burns over 3% TBSA
all full thickness burns over 1% TBSA
> 30%- PICU
when do children need IV fluids with burns and scalds
over 10% TBSA affected
-how much to give depneds on local guidance
-ask senior
what should always be considered when a child presents with burns and scalds
NAI
when should burns be referred 4
all burns over 3% TBSA
all full thickness burns over 1% TBSA
> 30%- PICU
burns in special areas- hands, feet, genitals and around joints
clinical signs of isotonic dehydration as a percentage of body weight
5% (milkd=50ml/kg) 4
lethargic
loss of skin turgor
dry mouth
fontanelle slack
clinical signs of isotonic dehydration as a percentage of body weight
10% (moderrate = 100ml/kg) 5
+
tachycardic
tachypneoa
fontaelle and eyes sunken
mottled skin
oliguria
clinical signs of isotonic dehydration as a percentage of body weight
15% severe >150ml/kg 3
+
shock
common
hypotension
investigations of acute diarrhoea 5
Hb
WBC
UnEs
bacteriology of stools x3
throat urine and blood cultures
when should IV feeds be considered in acute diarrhoea 4
unconcious
absent bowel sounds
10% or more dehyardated
shocked
fluid resus if shocked in acute diarrhoea
give plasma or 0.9% saline Iv 20ml/kg over 20 mins
IV fluids over 24hrs for acute diarrhoea
4% dextrose and 0.18% saline for 24hrs
when can bicarb be considered in acute diarrhoea
if acidosis is severe but care is needed
maintance fluid in infants and children
infant 150ml/kg
children 50-100 ml/kg inchildren
what do oral rehydration solutions contain
sodium potassium bicarb clorid glucose
when should ORS be used in acute diarrhoea
little and often to replace defiict
offere extra after each vomit or diarrhoea
breastfeeding should continue
how should food stuffs be reintroduced after acute diarrhoea
diluted whole/powered cows milk over 1-3days
starches within 1-2 days
*soy milk may be preferred for few days to avoid post enteritis lactose and cows milk intolerance
how does hypernatraemic dehydration fluid replacement compare to hyponatraemia
correcetd more slowly , over 24-72hrs to avoid convulsions
what should be monitoreed in acute diarrhoea 3
for signs of renal failure
weigh regularly
investigate blood biochem and gases
important complications of bacterial meningitis 7
- Reportable infection –protect other children in family, nursery and school by
reporting to public health. - Convulsions
145 - Cerebral oedema, subdural effusion, hydrocephalus
- Hyponatraemia from inappropriate antidiuretic hormone release
- Deafness: always screen hearing immediately on recovery
- Drug fever: rise of fever after initial fall
- Long term: mental handicap, cerebral palsy, epilepsy, deaf
empirical ABx for <6wk olds with bacterial meningitis 3
cefotaxime
amox
gent
empirical Rx for children over 3 months old with bacterial mengitis 2
cefotaxime
dexamthasone (4 weeks)
-ONLY IF NO PURPURA
common presentation of osteomyelitis 3
relctuance to use limb
local swelling
tenderness
*-this can porgress to a toxic looking specticaemic infant or child
which bone in paritcular is affected by osteomyeltits in infants
the femur
-early diagnosis and treatment are vital in preveenting damgage to the femoral head
investigations for osteomyeltis/ septic arthitis 4
blood cultures
Hb
WBC
X-rays
treatment of osteomyeltits/ septic arthirits (ABx regime):
- ≤5yo (1)
- ≥6yo(1)
≤5yo - cefuroxime
≥6yo Fluclox
THEN SWITCH BOTH TO ORAL CO-AMOX
immbolise the limb and watch
when is surgery indicated in osteomyelitits/septic arthirits:
-for infants
-for older children
infants- immediatley
older children- if poor response to treatment after 24hrs
syx of UTI in an infant 7
dysuria
frequency
haematuria
smelly urine
bed wetting (new/recurrence)
pyrexia of unknown origin
general malaise/non specific illness/not feeding
syx of UTI by age
-neonate 5
poor feeding
vomiting
fever
weight loss
conjugated jaundice
Boys>girls
syx of UTI by age
-preschool 5
vomiting
diarrhoea
failure to thrive
irritability and crying
fever
girl>boys
syx of UTI by age
-school age 4
localisation of pain to suprapubic/loin area
fever
polydipsia
polyuria
dysuria
common differentials for dysuria in older child 3
*-why is it still important to investigate for UTI
UTI
vulvitis
balinitis
*-untreated UTI may lead to renal scarring
investigations of UTIs 6
always check BP
Hb
WBC
UnEs
serum creatinine
urine and blood cultures
imaging for UTIs 1
-what abnormalities can be visualised 5
USS -cayceal radio isotope studies
look for:
-scarring
-pelvi-ureteric obstruction
-ureteral reflux
-duplex collecting systems
-bladder diverticuli/obstruction
common organism in UTIs for <1yo 1
E coli
common organisms in UTI 3
1/3 each
E Coli
Proteus
others
diagnostic values for a UTI dependent on sample collected
Clean catch urine or MSU
- two separate samples
>10(x5)/ml
catheters
>10(x4)/ml
any growth on suprapubic urine obtained by bladder puncture
diagnostic values for a UTI dependent on sample collected
Clean catch urine or MSU
- two separate samples
>10(x5)/ml
catheters
>10(x4)/ml
any growth on suprapubic urine obtained by bladder puncture
management of hypoglycaemia 2
oral gluocse if available
otherwise Iv glucose 0.5 g/Kg body weight as 50% solution
immediate action at home after poisoning 1
-when is this not appropriate 3
induce vomiting with fingers
-NOT SALT WATER
EXCEPT for
-volatile hydrocarbons
-caustics (irritating chemicals, oven cleaner,drain cleaner
-child unconcious
inital hospital assessment for poisoning
establish poisin
-its name
-amount
-when
-how
*consider non-accidental ingestion
how is vomiting induced in poisoning in the hospital and in what timeframe
*-when is this contraindicated
syrup of ipeacac 15ml + glass of water
-within 6 hrs of ingestion
-up to 24hrs for salicylates
-repeat after 20mins if no result
*CI in caustics, petrol or white spirit ingestion
inital poisoning management of unconcoisu 1
gastric lavage with protected airway
specific antidotes for poisoning
paracetamol
acetyl cysteine
antidotes for poisoning
tricylcis, opiates or slow realsing theophylline WITHIN ONE HOUR
actiavted charcoal
specific antidotes for poisoning
salicylate or phenobarbitone
alkali diuresis
specific antidotes for poisoning
iron
desferrioxamine
specific antidotes for poisoning
alcohol
glucose -hypoglycaemia may be severe
specific antidotes for poisoning
opiates, lomotil
naloxone
general management for poisoning 5
observation
monitor:
-airway
-circulation
-temp
-fluid balance
-blood glucose
signs of paracetomol overdose 5
assess for hepatotoxicity
-jaundice
-encephalopahty
N+V
abdo discomfort
hypoglycaemic
signs of opiate overdose 2
pinpoint pupils
respiratory depression
investgtions for paracetomol overdoses 4
LFTs
UnEs
coag
paracetomol level
management of paraccetomol overdose if presenting in first hour and then after
within 1hr since ingestion- activated charcoal
main treatment - N-aceytlcysteine
generally what level of paracetomol would indicate the need for N-acetyl cysteine
over 150mg/kg
J
J
when should N=acetyl cysteine be strated in a paracetomol overdose 3
blood paracetomol level above treatment line
staggered overdose/unclear time of ingestion
late presenation (after 24hrs)
indications for liver trasnplant after paracetomol overdose 3
arterial pH<7.3 24hrs after ingestion
or
-PT >100secs
creatinie >300 micromol/l
grade III or IV encephalopathy
clinical features of opiate toxiciity 6
reducece GCS
respiratory depression
pinpoint pupils
seizures\
muscle spasms
hypotension
managemtn of opitate toxicity
manage airway
naloxone
-usually 400micrograms
-can be repeated if required
-if requiring multiple doses consider infusion
causes of neuromalignant syndrome 4
haloperidol
droperidol
promethazine
etc
-dopamine blockers
MOA of neuromalignant syndrome
decreaed levels of dopamine
clinical features of neuromalignant syndrome 5
muscle cramps
tremors
pyrexia
sweating
rgidity
treatment for neuromalignant syndrome 2
cooling
dantrolene
cause of serotonin syndrome 4
SSRIs
SNRIs
MAOIs
MDMA
traid of features in serotonin syndrome
CNS effects -agitation, coma, altered mental state
autonomic instabbility - hyperthermia
neuromsulceu instabliity - clonus, elevated CK, hyperreflexia, rgiditiy
treatment of serotonin syndrome 4
cooling
supportive- eg IV fluids
benzos
more severe cases - cyproheptadine
antidote for benzo overdose
-caution with this drug
flumazenil
-hazardous- reduces seizure threshold particulrry in mixed overdoses involivng tricyclic antidepressants or benzo-dependet patients
clinical featueres of benzo overdose 6
drowsiness
bradycardia
hypotension
respiratory depression
coma
ataxia
dysarthia
nystagmus
what is included in an infection screen for a child with pyrezia 6
blood culutes
urine cultures ± LP
Hb
WBC
ESR
CXR
msot comomn cause sof seizures in a child
febrile convulsions
-in the absecne of fever- epilepsy must be considered
how is status epilepticus IN PAEDS defined
fit lasting more than 30 minutes
or
several fits with failure to regain consciousness between them
initial management of seizing child 3
move child from danger
place prone to avoid inhalationof vomit or saliva
losen clothing around neck
-do not attempt toprise open mouth
drugs given initaly for seizing child 2
give diazepam IV 1mg + 1mg for each year of life
-can be given as rectal prepartion
if no response after 10 mins
-paraldehyde 1ml for each year of life
-divided doses if morer than 2ml into each buttock
(phenytoin is an alteritive)
when should general anaestghesia be consdered for a sezing child
if no respone to both drugs and duration longer than 30 minutes
what important complication must be considered in a seizing child (1) and how is this combated (3)
cerebral oedema
-restrict fluid and consider mannitol and dexamethasone
important investigation in a prlonged sezing child
blood glucose
when should LP be considered in a seizing child 4
if first febrile convulsions under 2 years old
prolonged
focal
if meningism is present
specific treatment for infantile spasms 2
ACTH injections or coritocosteroids
+
benzo, eg nitrazepam
specific treatement for petit mal seizures 2
ethosuximide
valporate
specific treatment for temporal or focal epilepy 2
carbamazepine
phenytoin
definition of sudden infant death syndrome
sudden and unexpceted death after which an autopsy fials to reveal a major cause of death
predominantly 1month to 1 year old
risk factors for sudden infant death syndrome4
boy
LBW
winter
adversre social and domestic conditiosn
managemtn of sudden infant death syndrome 6
resus may be appropriate
if hsitory and exam do not sugegst prior illess or injury
and no suspcicion of parents
-should be told cot death (SIDS) is likely
coroner- inform police, get autopsy , take statements
inform family doc, health visotrs an d social sevrvices
suppress lactation if breast feeding
define non-accidental injury
abuse is/was infliced or knowinlgy not prevented by person caring for child
and
signs are present
what are potential signs of non accidental injury 5
physical injruy
neglect
drug administriation
failure to thrive
emotional or sexual abuse
commonn presentation of non accidental injury 3
injuries inconisitente with explination
delay in seeking help
medical advice sought for repeated minor injuries
risk facgtors for parents to inflict non accidnetal injury 5
young
single
mentally ill
known to social services
low IQ
which conditions can cause adrenal insufficiency in a child 4
any child on daily replacement hydrocortisone treatment
for example:
-congenital adrenal hyperplasia
-congenital adrenal hypoplasia
-adrenal insuffiency
-multiple pituitary hormone defiency
management of child on hydrocortisone replacement with an incurrent illness
-is stilll well, feeding playing and tolerating normal meds
no need to increase steroids
management of child on hydrocortisone replacement with an incurrent illness
-is unwell with fever and reduced acitivty
if tolerateing oral meds:
-double largest daily hydrocoritsone dose and administer three times per day for 48hrs
eg, if normally on 10mg morniing and 5 mg eveing-> give 20mg three times/day for 48hrs
management of child on hydrocortisone replacement with an incurrent illness
-severely unwell /unresponsive/vomitting 6
check BM, UnEs and FBC
if BM <3mmol/l give 2ml/kg of 10% dextrose
fluid bolus if inidcated
give IV hydrocort bolus and start IV infusion
start IV maintenance fluids
consider double dose hydrocor therapy once tolerating oral meds
who is at risk of diabetes insipidus
children with suprasellar tumours
-particularly craniopharyngiomas
what is a diagnosis of diabetes insipidus based on 2
elevated plasma osmolality due to hypernatraemia
AND
inapporpriately dilute urine
sx and syx of diabetes insipidus 3
polydipsia
polyuria
dehydration/weight loss
urine output to consider diabetes insipidus
5ml/kg/hr for 2 consecutive hours
plasma sodium value to consider diabetes insipidus
> 145mmol/l
serum and urine osmolatitly to consider diabetes insipidus
plasma >295 mOsmol/kg
urine <450 mOsmol/kg
dipstick results in diabetes insipidus
specific gravity <1.005
observatiosn for diabetes insipidus
strict fludi input and output - 4 hourly balances
daily weights 8am and 8pm
regulary UnEs
prinicples of management for diabetes insipidus
monitor Na+ and urine output
make fluid replaceemnts
DDAVP administration
DO NOT OVER CORRECT- hypernatraemia is better than hyponatraemia
management of diabetes insipidus if pateitn hypernatraemia (>150mmol/l
increase IV fluids ± further dose of DDAVP
management of diabetes insipidus if sodium in normal range 135-145mmol/l
do not give further DDAVP
-monitor Na 4-6hrly and fluid balance
indications for hypothyroidism in infants
guthrie heel spot test
-TSH high-> suggests hypothyroidism
confirmatory tests of hypothyroidisim 2
pre-treatment thyroid function tests
-TSH and T4
quantitative thyrodglobulin
optional confirmatiory tests for hypothyroidism
thyroid imaging - US ± radioisotop scans of neck
thyroid antibodies
maternal TFTs
thyroid antibodies to test for in hypothyroidism 2
thyroid peroxidates
TSH receptor antibodies
treatment of hypothyroidism in childrne
replacement therapy with lebothyroxine
