Paediatric emergencies Flashcards
Sepsis in children HIGH RISK criteria, initial Ix?
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)
Contraindications to LP
Signs of raised ICP
focal neuro signs
Shock
Purpura
Perform LP if under 3m?
If suspected sepsis
<1m
1-3m who appear unwell
1-3m w/WCC <5 or >15
Children w/moderate to high risk sepsis Bloods:
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
Children w/ high risk sepsis Ix
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
ABx for sepsis in children
If meningococcal: IM benpen, IV ceftriaxone Follow g/l Neonates in first 72hrs: IV benzylpenicillin and gentamicin
Paediatric sepsis 6
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
Anaphylaxis in children
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
PACES anaphylaxis
Severe allergy rn: treat pt. stabilise In future: will go to allergy clinic Discuss: - carrying epipen - lying flat - raising legs - administering adrenaline - call 999
Neonatal Resus Guidelines
- Dry baby, remove wet towels and covers, start timer
- Within 30s: assess tone breathing and HR
- within 60s: if gasping/not breathing open airway and give 5 inflation breaths
- Reassess: if no inc. HR look for chest movement
- If chest not moving: recheck head position, consider airway manoeuvres, repeat inflation breaths
- If NO inc. HR look for chest movement
- When chest moving: if HR<60 ventilate for 30s
- Reassess HR: if still <60 start CCs with ventilation breaths (3:1)
- Reassess HR every 30s, if undetectable or slow consider atropine
Paeds BLS
- responsive?
- shout help
- open AW
- look listen feel breathing
- 5 rescue breaths
- Check signs of circulation] (brachial and radial)
- 15:2 CC and rescue breaths
Hypogylcaemia Mx
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
DKA Initial Mx
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
DKA fluid and insulin Rx
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)
Fluid deficit calc. in DKA
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
Maintenance fluid req. in DKA
<10kg = 2ml/kg/hr
10-40kg = 1ml/kg/hr
40+kg= 40ml/hr
NB are lower than standard maintenance bc risk of cerebral oedema
Which fluids in DKA
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
Monitoring during DKA therapy
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
hypokaelamia on ECG
ST depression
prominent U waves
Flattened P waves
Cx of DKA
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
Non accidental injury presentations
bruising fractures drowsiness (subdural) neglect FTT
If suspecting NAI
refer to senior
contact named doctor for childhood protection
contact social services and refer
?contact CAIT and MASH
NAI Ix
skeletal survey
CT head
blood and bone profile to rule out leukaemia, ITP
Fundoscopy
