Paediatric emergencies

Question 1

Sepsis in children HIGH RISK criteria, initial Ix?

Answer 1

Beahviour: no response, appears ill, does not stay awake, weak high pitched cry
Heart rate: tachycardia or <60
RRL tachy, grunting, apnoea, <92% OA
Mottled skin, ashen
Cyanosis of skin, lips, tongue
Non blanching rash
<3m temp >38
temp <36
TRANSFER IMMEDIATELY to acute hosp setting
If suspected meningococcus IM benzylpenicillin
ID source:
(FBC, culture, CRP, urine, ?LP, CXR)

Question 2

Contraindications to LP

Answer 2

Signs of raised ICP
focal neuro signs
Shock
Purpura

Question 3

Perform LP if under 3m?

Answer 3

If suspected sepsis
<1m
1-3m who appear unwell
1-3m w/WCC <5 or >15

Question 4

Children w/moderate to high risk sepsis Bloods:

Answer 4

VBG:
blood gas including glucose and lactate
blood culture
FBC
CRP
U+E
Creatinine
R/v venous lactate within 1hr:
- Lactate >2mmol or evidence of AKI treat as HIGH risk
- Lactate <2mmol: at least hrly r/v, senior clinician within 3hr

Question 5

Children w/ high risk sepsis Ix

Answer 5

Immediate r/v by senior
VBG:
- blood gas (inc glucose and lactate)
FBC
CRP
U+E
Creatinine
Clotting screen
Give BS ABx w/o delay at MAX dose
Continuous monitoring (including LOC)
Lactate >4: IV fluid bolus immediately, refer to critical care
Lactate 2-4: IV bolus w/o delay
Lactate <2:consider IV fluids

Question 6

ABx for sepsis in children

Answer 6

If meningococcal:
IM benpen, IV ceftriaxone
Follow g/l
Neonates in first 72hrs:
IV benzylpenicillin and gentamicin

Question 7

Paediatric sepsis 6

Answer 7

Give:
1. High flow O2
2. Abx
3. Fluids (10-20ml/kg isotonic over 5-10 mins, repeat until urine o/p: 0.5ml/kg/hr)
Take:
4. IV access for: gases, lactate, glucose, cultures
Specialist:
5. Involve senoir early
6. Consider inotropes early

Question 8

Anaphylaxis in children

Answer 8

ABC
Position comfortably (sitting up if Dib, raise legs if low BP, ?recovery)
IM adrenaline 1:1000
- in thigh, assess response at 5m
- repeat every 5m
IV adreanaline NOT in primary care (only in cardiopulmonary arrest)
High flow O2
IV fluids
IV chlorphenamine 10mg+IV hydrocortisone 200mg

Question 9

PACES anaphylaxis

Answer 9

Severe allergy
rn: treat pt. stabilise
In future: will go to allergy clinic 
Discuss:
- carrying epipen
- lying flat
- raising legs
- administering adrenaline
- call 999

Question 10

Neonatal Resus Guidelines

Answer 10

1. Dry baby, remove wet towels and covers, start timer
2. Within 30s: assess tone breathing and HR
3. within 60s: if gasping/not breathing open airway and give 5 inflation breaths
4. Reassess: if no inc. HR look for chest movement
5. If chest not moving: recheck head position, consider airway manoeuvres, repeat inflation breaths
6. If NO inc. HR look for chest movement
7. When chest moving: if HR<60 ventilate for 30s
8. Reassess HR: if still <60 start CCs with ventilation breaths (3:1)
9. Reassess HR every 30s, if undetectable or slow consider atropine

Question 11

Paeds BLS

Answer 11

1. responsive?
2. shout help
3. open AW
4. look listen feel breathing
5. 5 rescue breaths
6. Check signs of circulation] (brachial and radial)
7. 15:2 CC and rescue breaths

Question 12

Hypogylcaemia Mx

Answer 12

Advise carrying immediate fast acting glucose and glucose monitoring equipment
Mild-mod.:
PO fasting acting glucose
recheck glucose within 15m and repeat if necesary
As Sx improve give long lasting card
SEVERE:
Hospital IV10% glucose (max dose 500mg/kg)
if not in hospital: IM glucagon or conc. oral glucose
Glucagon: 500ug <8y 1mg if >8
NB alcohol a major risk factor for hypos so carbs with drinking

Question 13

DKA Initial Mx

Answer 13

Record: LOC, vital signs, Hx N+V, dehydration, body wt
Measure: pH pCO2, U+E, plasma bicarb
1to1 nursing if: <2y, Severe
Consider NG tube if reduced LOC and vomiting
Consider inotropes
?sepsis

Question 14

DKA fluid and insulin Rx

Answer 14

PO fluids and Sc insulin if child ALERT, no Hx N+V, not dehydrated
Monitor ketones and pH
OR IV fluids + insulin
calculate total fluid req. by adding estimated deficit to maintenance
Start IV insulin infusion 1-2hr after beginning IV fluids in DKA (0.02-0.1u/kg/hr) NOT bolus, disconnect pumps
If ketones not dec. after 6-8hr increase dose
Begin sc insulin at least 30min before stopping IV
Begin pump 1hr before (change site and new cannula)

Question 15

Fluid deficit calc. in DKA

Answer 15

5% fluid deficit in mild-mod DKA (pH>7.1)
10% if pH <7.1
Fluid deficit vol. = %deficit x weight x 10
Do NOT use bolus w/o senior approval
If approved: 10ml/kg
NB. Deficit shoud be replaced over 48hr

Question 16

Maintenance fluid req. in DKA

Answer 16

<10kg = 2ml/kg/hr
10-40kg = 1ml/kg/hr
40+kg= 40ml/hr
NB are lower than standard maintenance bc risk of cerebral oedema

Question 17

Which fluids in DKA

Answer 17

0.9% saline w/o glucose used for rehydration and maintenance until glucose <14
then 0.9% w/5%glucose
NB ensure all fluids have 40mmol KCl (unless renal failure)
?urinary catheter

Question 18

Monitoring during DKA therapy

Answer 18

At least hrly:
glucose, vital signs, fluid status, LOC (record LOC, HR every 30m if <2y or severe)
continuous ECG for hypokaelamia
At 2 hrs and at least 4hrly:
Glucose (lab), pH and pCO2, U+E, beta-hydroxybutyrate
Clinical status

Question 19

hypokaelamia on ECG

Answer 19

ST depression
prominent U waves
Flattened P waves

Question 20

Cx of DKA

Answer 20

Cerebral oedema: mannitol or hypertonic NaCl
Sx = headache, high BP low HR
Hypokalaemia (<3): consider temporarily stopping insulin, ?central venvous catheter for >40mmol KCl
VTE - increased risk esp with central line

Question 21

Non accidental injury presentations

Answer 21

bruising
fractures
drowsiness (subdural)
neglect
FTT

Question 22

If suspecting NAI

Answer 22

refer to senior
contact named doctor for childhood protection
contact social services and refer
?contact CAIT and MASH

Question 23

NAI Ix

Answer 23

skeletal survey
CT head
blood and bone profile to rule out leukaemia, ITP
Fundoscopy