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Paediatrics > Paediatric emergencies > Flashcards

Paediatric emergencies Flashcards

1
Q

Anaphylaxis

A

85% food allergy, usually IgE

CF: sudden onset rapidly progressive skin/mucosal signs of urticaria/angioedema (usually but not always), stridor/wheeze, tachypnoea, cyanosis, pale/clammy/hypotension/drowsy/coma

M: sit up to help breathing, elevate legs, BLS/ALS if needed. IM adrenaline 1:1000 can repeat every 5m (150 micrograms if 1m-5y, 300 mcg if 6-11y, 500 mcg if 12-17y unless small), high flow O2 if needed, IV fluids 20ml/kg, IM/IV hydrocortisone, IM/IV chlorphenamine, salbutamol for wheeze

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2
Q

Encephalitis

A

Inflammation of brain parenchyma by enterovirus/influenza/herpesvirus

Causes: direct invasion by virus e.g. HSV (rare in children but v bad), post-infectious encephalopathy e.g. after chickenpox, slow viral infection e.g. subacute sclerosing pan-encephalitis after measles, or non-infectious (metabolic)

CF: most have fever, altered consciousness, seizures, may have insidious onset w behavioural change

M: initially meningitis until excluded. High dose IV acyclovir until HSV ruled out (with PCR of the CSF), if proven HSV treat IV for 3w (otherwise supportive)

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3
Q

Bacterial meningitis

A

Path: usually a bacteraemia is the cause (tho can be local spread of infection) - host response causes oedema, RICP, reduced cerebral blood flow + cerebral cortical infarction

Organisms: <3m GBS/E coli/Listeria/S pneumonia/Staph aureus, 1m-6y N meningitides/S pneumoniae/Hib, >6y N meningitides/S pneumonia [Hib seen less now cos of vaccine]

CF:

  • Non specific esp in younger can occur
  • Signs of shock like tachycardia/pnoea, prolonged CRT, hypotension
  • Symptoms: fever, headache, photophobia, lethargy, poor feeding, vomiting, irritability, hypotonia, drowsy, loss of consciousness, seizures
  • Signs: fever, purpuric rash, neck stiffness, bulging fontanelle (<18m), opisthotonus (arching back), signs of shock, focal neuro signs, altered GCS, papilloedema (rare)
  • Brudzinski sign (flex neck when supine causes knee+hip flexion), Kernig sign (when supine with flexed hip + knees, extending knee causes back pain)

Ix: LP, rapid antigen test for meningitis organisms from blood/CSF, viral PCR samples (throat swab/NPA), bloods (culture, FBC, glucose, gases, clotting, CRP, U+E, LFT), urine/stool culture, consider CT/MRI brain

M: 3rd gen cephalosporins IV e.g. ceftriaxone (covers commonest organisms), beyond neonatal period dexamethasone to reduce swelling

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4
Q

Non-bacterial meningitis

A

Viral: >2/3 CNS infections are viral. EBV, enterovirus, adenovirus, mumps. Usually less severe than bacterial but can be similar sx

Uncommon causes: suspect when atypical CF/failure to respond to Abx. May include mycoplasma, Lyme disease (Borrelia burdoferi), fungal.

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5
Q

Cerebral complications of bacterial meningitis

A

Hearing impairment-damage to cochlear hair cells
Local vasculitis-CN palsies
Local cerebral infarct-seizures, epilepsy
Subdural effusion: esp in Hib/pneumococcal
Hydrocephalus: impaired resorption (communicating) or blocked ventricular outlet/cerebral aqueduct by fibrin (non-communicating)
Cerebral abscess: deterioration, signs of SOL, fluctuating temp

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6
Q

What are common poisons in children, and which should you particularly worry about?

A

Low toxicity: oral contraceptives, most Abx, topical hydrocortisone, liquid soap, lipstick, washing up liquid, fish food, water-based glues/paints, slugs, geraniums, compost

High toxicity: opioids, beta blockers, TCAs, oral hypoglycaemic, paracetamol, digoxin, iron, salicylates, bleach, concentrated oven cleaner, liquid nicotine, anti freeze, petroleum distillates, death cap mushroom, yew, foxglove, organophosphates, kerosene

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7
Q

How should you manage poisoning in children?

A

Identify the toxin

Determine toxicity: intrinsic toxicity from poisons info services like ToxBase, reported dose ingested, presence of sx, time since ingestion

Activated: can reduce absorption if given within 1h. Ineffective for iron, hydrocarbons and pesticides

Ix: depends on what has happened, general bloods, specific blood concs for some, ECG if CV toxicity possible, urine toxicology to confirm diagnosis

M: depends obv, may use an antidote (in poisons info service), CAMHS in OD

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8
Q

Paracetamol toxicity

A

CF: abdo pain, vomiting, liver failure (12-24h)

Mech: gastric irritation, saturation of liver met so accumulate NAPQI

M: plasma paracetamol conc plotted against time, threshold on graph for initiating N-acetylcysteine (also given if abnormal LFT or INR; ALT most sensitive)

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9
Q

Button battery ingestion

A

CF: abdo pain, gut perforation, strictures (they are v corrosive)

M: XR chest + abdomen to confirm, endoscopic removal

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10
Q

CO poisoning

A

CF: headache, nausea, confusion, drowsy, coma. Binds to Hb causing tissue hypoxia

M: high flow O2 to hasten dissociation

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11
Q

Salicylate toxicity

A

CF: vomiting, tinnitus, resp alkalosis –> metabolic acidosis, hypoglycaemia

M: alkalisation of urine to increase excretion, haemodialysis if svere

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12
Q

TCA toxicity

A

CF: tachycardia, dry mouth, arrhythmia, seizure

M: sodium bicarb for arrhythmias, support ventilation

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13
Q

Ethylene glycol (antifreeze) ingestion

A

CF: tachycardia, metabolic acidosis, renal failure

M: fomepizole (inhibits toxic production of metabolites), maya also use alcohol but more s/es, harm-dialysis if severe

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14
Q

Alcohol toxicity

A

CF: hypoglycaemia, coma, resp depression. Due to inhibition of glycolysis + effects on neurotransmission in brain

M: monitor BGL, blood alcohol levels help predict severity

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15
Q

Iron toxicity

A

CF: D+V, haematemesis/melaena, acute gastric ulcer. Latent period of improvement then 6-12h later drowsy coma shock liver fiaulre hypoglycaemia convulsions (later effects due to mitochondrial disruption + metabolic acidosis)
M: IV desferoxamine to chelate iron

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16
Q

Hydrocarbon toxicity e.g. kerosene

A

CF: pneumonitis, coma

M: supportive

17
Q

Organophosphate ingestion

A

CF: salivation, lacrimation, urination, D+V, muscle weakness/cramps/paralysis, bradycardia, hypotension, seizures, coma (inhibits AChE – ACh accumulates)

M: atropine (anti-cholinergic), pralidoxime (reactivates AChE)

18
Q

Signs of anticholinergic OD (e.g. TCA, antihistamines)

A

Raised HR + BP
Fever
Dilated pupils
Reduced sweating

19
Q

Signs of opioid OD

A

Reduced HR+BP+RR
Hypothermia
Constricted pupils
Reduced sweating

20
Q

Signs of sympathomimetic OD e.g. cocaine/amphetamines

A

Increased HR, BP, RR
Fever
Dilated pupils
Increased sweating

21
Q

Signs of sedative/anticonvulsant OD

A

Reduced HR, BP, RR
Reduced temp
No effect on pupils
Reduced sweating

22
Q

Signs of lead poisoning

A

Chronic: behavioural change, hyper/hypoactivity, developmental delay, chronic lead nephropathy

Severe: abdo pain, vomiting,§ constiption, headache, ataxia, lethargy, seizures, coma

Acute -chelation therapy

23
Q

Respiratory failure

A

Moderate: tachycardia/pnoea, nasal flaring, accessory muscle use, IC+SC recession, head retraction, not feeding

Severe: cyanosis, tiring, reduced consciousness, sats <92% despite O2 therapy, rising pCO2

M: oxygen if <92% (via NC/face mask), NIV with CPAP/BPAP to humidify gas, invasive ventilation with ETT when severe like tiring/progressive hypercapnia/NM weakness e.g. GBS

24
Q

Sepsis

A

Bacteraemia - host response - inflammatory cytokines + activation of endothelial cells

Cases: coagulase negative Staph (often a skin contaminant though!), S aureus, N meningitidis, E coli.

M: sepsis 6.
ABx choice: in GP can give stat IM benpen whilst send to hosp. Neonates first 72h benpen + gentamicin (as GBS main cause), babies <3m ceftriaxone + amoxicillin/ampicillin (to cover listeria), children up to 17y ceftriaxone

Comps: pulmonary oedema + resp failure, myocardial dysfunction (may need inotropes), abnormal clotting like DIC cos of consumption of clotting factors + microvascular thrombosis (FFP + cryoprecipitate + plts)

25
Q

Shock

A

When circulation can’t meet metabolic demands of the tissue. Children more susceptible as higher SA:V ratio + higher BMR

Causes: hypovolaemia (sepsis, dehydration, DKA, blood loss), maldistribution of fluid (sepsis, anaphylaxis), cardiogenic (arrhythmias, HF), neurogenic (e.g. SC injury)

CF:

  • Early signs from compensation. So BP maintained by raised HR+RR, signs of dehydration, mottled pale cold skin
  • Late signs from decompensation. Acidotic breathing, bradycardia, hypotension, confusion, blue peripheries, absent UO

M: fluid resuscitation, then replacement + maintenance. If no improvement need PICU for intubation/invasive BP monitoring/inotropic support/correction of blood derangements/renal support

26
Q

Status epilepticus

A

Seizure lasting >5 min, or multiple seizures without full recovery

A-E, high flow O2, measure glucose

Lorazepam IV/IO, or buccal midazolam/rectal diazepam (get vascular access after giving this)

Repeat lorazepam

Prepare phenytoin, senior help obv

Treat reversible causes like hypoglycaemia or electrolyte disturbance

27
Q

Unconscious child

A 
Post-ictal status
Infection e.g. meningitis, encephalitis
Metabolic e.g. DKA, hypoglycaemia, calcium/sodium/magnesium disturbance, inborn error of metabolism
Head injury, ICH
Drug/poison ingestion
28
Q

Grading burn depth

A

Burn=dry heat, scald=wet heat (inhaling can cause significant airway swelling)

Burns graded as follows:

  • Superficial (just epidermis) e.g. sunburn or minor scald. Dry + erythematous, painful, heals rapidly in a week
  • Partial thickness superficial (a bit in dermis) e.g. scald. Moist, erythematous, blistered, painful, heals 1-3w
  • partial thickness deep (deeper in dermis) e.g. scald, brief contact with flame. Moist, white slough, erythemaotus/mottled, painless, 3-4w healing + often needs grafting
  • Full thickness (through full dermis) e.g. significant flame contact. Dry, charred, white, painless, needs skin grafting
29
Q

Burns management

A

First aid: cool with running water but avoid hypothermia for up to 20m, irrigate chemical burns copiously, plastic cling wrap to limit evaporation, pain relief (e.g. intranasal opiates)
Estimate burn SA with diaphragm. Roughly 1% SA is size of the child’s palm
Regular analgesia
IV fluids if >10% SA affected
Wound care: depends on depth. Exposure for superficial, small superficial PT clean + dress, partial thickness bigger/deeper specialist burns surface, any burn to hands/feet/perineum/face/ears/eyes/major joint need specialist burns service
Consider safeguarding

30
Q

Sudden infant death syndrome

A

Peak age 2-4m, previously well. Majority natural but unexplained, rarely suffocation.
RF: co-sleeping, lying on back to sleep, overheating, parental smoking, prematurity

31
Q

What fluid replacement + maintenance regimes would you use for children?

A

Replacement fluids: weight (kg) * dehydration % * 10. If clinically dehydration assume 10% dehydrated. Correct over 48h with 0.9% saline + 5% dextrose

Maintenance: for 24h. 100ml/kg for first 10kg, 50ml/kg for second 10kg, 20ml/kg for any subsequent kg

32
Q

What observations should be recorded in all febrile children?

A

Temp, HR, RR, cap refill time

Also look for signs of dehydration

33
Q

What are amber flag signs in a child with fever?

A
  • Pallor reported by parent, not responding normally to social cues, wakes only with stimulation, reduced activity
  • Resp: nasal flaring, tachypnoea (>50 6-12m, >40 1y+), sats 95% or less, crackles on chest
  • CVS: tachycardia >160 <12m, >150 12-24m, >140 if 2-5y; CRT 3s or more, dry mucus membranes, poor feeding, reduced urine output
  • Any child 3-6m with temp 39 or more
  • Fever for 5+ days, riggers, swelling of a limb/joint, non weight bearing limb/not using an extremity
34
Q

What are red flag signs in a child with fever?

A
  • Pale/mottled/ashen/blue, appears ill to a HCP, no response to social cues, not waking, weak high pitched cry
  • Resp: grunting, tachypnoea >60, moderate/severe chest indrawing
  • Reduced skin turgor
  • Any child <3m with a temp of 38 or more
  • Non blanching rash, bulging fontanelle, neck stiffness, status epilepticus, focal neuro signs, focal seizures
35
Q

What should be done if a child has amber flags with a fever?

A
  • Safety net - verbal/written info on warning symptoms + how to access further healthcare/FU appointment/other HCP
  • or refer to paeds for further assessment
36
Q

What should be done if a child has red flags with a fever?

A

Refer urgently to paediatric specialist

37
Q

What is the management of meningitis in children?

A
  • IV Abx: <3m amoxicillin + cefotaxime (cover listeria), >3m cefotaxime
  • Dexamethasone if >1m and caused by H influenzae
  • Fluids for shock
  • Cerebral monitoring, mechanical ventilation if respiratory impairment
  • Public health notification, Abx prophylaxis for close contacts (usually ciprofloxacin now instead of rifampicin)

Paediatrics (18 decks)

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