Paediatric Emergencies - Altered Consciousness, Epilepsy, Poisoning and Meningitis Flashcards
What can cause altered consciousness?
Almost anything
Head trauma Toxins Infection Metabolic causes Brain tumour Seizure etc
What is important to ask about on history if a child presents with altered consciousness?
Onset - Gradual or Sudden? Previously unwell? Feed Trauma PMH of seizures
How are children with altered consciousness managed?
A-E approach
What parts of the A-E approach are particularly important when assessing a child with altered consciousness?
Breathing pattern can indicate brain injury & smell breath for alcohol, toxins and ketones
C - admission bloods, clotting, lactate, culture and ABG
D - esp. pupils and glucose
E - Medical ID tag, signs of non blanching rash? Jaundice, fontanelles?
If the cause remains unknown after the A-E approach, what would be your next steps?
CT Head
EEG
Lumbar Puncture
Treat for meningitis/encephalitis if history fits
How would Raised Intracranial Pressure present in a child?
Bulging fontanelles Loss of Consciousness Unequal/unreactive pupils Headache and vomit Abnormal resp. pattern Hypertension and bradycardia Muscle flaccidity Papilloedema
What are the contraindications to lumbar puncture in a child?
Reduced consciousness (GCS <13) Septic shock Likely invasive meningococcal disease Signs of RICP Focal neurology Bleeding tendency
What is status epilepticus?
Any seizure lasting > 30 mins
OR
Series of seizures over a >30 min period without regain of consciousness
However for purpose of nice guidelines start treatment at 5 mins
What can cause status epilepticus?
Epilepsy Fever Febrile convulsion Head trauma CNS infection Poisoning Metabolic disturbance
What is done immediately when a child is in status epilepticus?
A-E assessment
High flow O2
Check glucose
What is done after 5 minutes if the status epilepticus doesn’t resolve?
Buccal Midazolam 300 mcg/kilo if <2 month 2.5mg/kg 3-11 months 5mg/kg 1-4 years 7.5mg/kg 5-9 years 10mg/kg 10-17 years
IV lorazepam
100mcg/kg <11 years old
4mg if 12-17years old
What would you do if status epilepticus isn’t resolving after 15 minutes even following treatment?
Call for senior help
IV Lorazepam 2nd dose
What would you do if status epilepticus hasn’t resolved after 25 minutes despite treatment?
Inform ITU
IV Phenytoin infusion - 20mg/kg
What would you do if status epilepticus hasn’t resolved after 45 minutes despite treatment?
Rapid sequence induction of anaesthesia
What investigations must be done following life supporting treatment for status epilepticus?
ABG Calcium Magnesium Clotting Anti-Epileptic drug level EEG Imaging Lumbar Puncture
When do most cases of poisoning occur?
Toddler accidentally ingest something they shouldn’t
What can be other causes of poisoning in children?
Adolescents - self harm
Deliberate poisoning
What must you establish in the history?
Exactly what was ingested - name, brand, concentration
When they ingested it
How much they ingested
What investigations should be done following a child coming in with poisoning?
Urine toxicology screen ABG Carboxyhaemoglobin ECG Abdo X-Ray
What should the examination of a poisoned child include?
Inspection of oropharynx and vomitus
Assess level of consciousness
What possible management options are there for swallowing?
Activated charcoal - 1g/kg within 1 hour of ingestion
Specific treatments for certain drugs and toxins
Gastric lavage
Ipecacuanha
Bowel irrigation
What must be done if the poisoning is due to deliberate self harm?
Admit to hospital for psychiatric assessment
What can Iron overdose cause and how is it treated?
Shock and Gut Haemorrhage
IV Desferrioxamine
What can paracetamol overdose cause and how is it treated?
Liver failure
IV N-Acetylcysteine
What do salicylate overdose cause and how is it treated?
Widespread cellular damage and cardiac dysrhthmias
Ethanol
Dialysis if severe
Alkalinize urine with bicarbonate
Anti-arrhythmic
How is ecstasy overdose treated and what does it cause?
Hyperpyrexia and rhabdomyolysis and dysrhythmia
Active cooling
Benzodiazepines
What group of organisms normally causes meningitis?
Viruses
What do you do differently for viral meningitis than for bacterial?
Treat the same as you can’t differentiate between them clinically
What are the main bacteria that cause meningitis is neonates?
Grou B Strep
E Coli
Listeria Monocytogenes
What are the main bacteria that cause meningitis in infants?
Neiserria Meningitidis
Strep Pneumoniae
What are the main bacteria that cause meningitis in children?
Neiserria Meningitidis
Strep Pneumoniae
Haemophilus Influenzae
What is meningitis?
Inflammation of the leptomeninges and CSF
In what ways can meningitis spread?
Direct spread - penetrate skin and skull or nasal mucosa
Haematological
What symptoms would make you wary of meningitis?
Headache Vomiting Stiff neck Photophobia Purpuric rash Altered mental state Kernig and Brudzinski's signs Pain Fever Cold extremities and long cap refill
What is Kernig’s sign?
Can’t straighten leg when hip is flexed to 90 degrees due to back pain
What is Brudzinski’s sign?
Patient’s hip and knees flex when neck is flexed
What investigations must you do if you query meningitis?
Bloods - CRP, FBC, Coag screen, PCR for N Meningitidis, glucose
Lumbar puncture unless contraindicated
Nasal swabs
When should you start treatment if you query meningitis?
Straight away!
Don’t wait for investigations
What signs on lumbar puncture are indicative of bacterial meningitis?
Raised protein, neutrophils
Low glucose
What signs on lumbar puncture are indicative of viral meningitis?
Protein raised or normal Glucose low (but not as low as bacterial) Raised lymphocytes
What are the main risk factors for neonatal meningitis?
Premature birth
Low birth weight
Traumatic delivery
How does neonatal meningitis present?
Non specific symptoms!
Raised or lower temp Respiratory distress Hypotension Bradycardia Poor feed
What are the short term complications of meningitis?
Acidosis Low K+, Ca2+, Mg2+ and glucose Coagulopathies Seizures Raised ICP
What are the long term complications of meningitis?
Hearing loss Scars from necrosis Limb loss Renal failure Psychosocial problems
How do you manage a patient with meningitis in the short term?
Resus with A-E approach
IV Ceftriaxone for 7 days
Dexamethasone
IV Cefotaxime + Amox for <3 months
What antibiotic would you use for H Influenzae B and for how long?
IV Ceftriaxone for 10 days
What antibiotic would you use for S Pneumoniae and for how long?
IV Ceftriaxone for 14 days
What antibiotic would you use for L Monocytogenes and for how long?
IV Amoxicilin for 21 days
Gentamicin for 7 days
What antibiotic would you use for Gram -ve bacilli and for how long?
IV Cefotaxime for 21 days
