Paediatric Emergencies - Fever, Anaphylaxis and Shock Flashcards
How is fever defined and how is it measured in a child?
> 38 degrees
Measured with electronic tympanic membrane thermometer
What questions are important to ask a feverish child?
How long have they been febrile?
Any localising symptoms - cough, D&V, painful limb, abdominal pain, headache
Recent foreign travel
What investigations would you request for a feverish child?
Inflammatory markers - WCC, Neutrophils, CRP
Swabs for microscopy and culture
Chest X-Ray?
Septic screen
What can a fever of more than 1 week be characteristic of?
TB Kawasaki disease Malaria Typhoid Autoimmune non-infectious disorders Malignancy
What are some common major illnesses that cause fever?
Meningitis
Pneumonia
UTI
Septicaemia
What are some common minor illnesses that cause fever?
URTI
Non specific viral infection
Gastroenteritis
What signs/symptoms are indicative of “serious sepsis”? (Stupid phrase, all sepsis is serious 🙄)
ILLNESS
Irritability Lethargy Low cap refill Neutropenia or neutrophilia Elevated or low temperature
Serious
Sepsis
What types of causes can lead to pyrexia of unknown origin?
Infective
Inflammatory
Malignancy
Factitious fever
What inflammatory causes lead to pyrexia
Kawasaki disease
RA
Crohn’s
What system is used to assess a fever?
Traffic light system
Green - send home with advice
Amber - Send home with safety net or to hospital for assessment
Red - urgent hospital assessment
What categories are in the NICE traffic light system for identifying serious fever?
Colour Activity Respiratory Hydration and Circulation Other
How does colour of the patient determine their relative level of risk?
Green - normal colour
Amber - pallor reported by parent/carer
Red - pale, mottled, ashen or blue
How would a child at low risk of serious illness be acting?
Respond normally to social queues
Content and smiling
Stay awake or awaken quickly
Strong normal cry or not crying
What actions would place a child at medium risk of serious illness?
Not responding normally to social cues
Walking only with prolonged stimulation
Decreased activity
Not smiling
What activities would place a child in the high risk category of serious illness?
No response to social cues
Appear ill to healthcare professional
Unable to rouse/won’t stay awake
Weak, high-pitched or continuous crying
What respiratory changes would place a child at medium risk of serious illness?
Nasal flaring Tachypnoea: 6-12 month >50 >12 months >40 O2 says <95% Crackles
What respiratory changes would place a child at high risk of serious illness?
Grunting
Tachpnoea >60
Moderate or severe chest in drawing
What changes to hydration and circulation places someone in the amber category (for serious illness)?
Dry mucous membranes
Poor feeding - infants
Cap refill >3s
Reduced urine output
Tachycardia:
<1 year - >160bpm
1-2 years - >150bpm
2-5 years - >140bpm
How do you test cap refill in a newborn infant?
Press on sternum for 5 seconds
What hydration changes would you expect to see if a child was at high risk of serious infection?
Reduced skin turgor
What other signs could place a child in the amber category (serious illness)?
Fever >= 5 days Rigors if 3-5 months Temp >=39 Swelling of limb or joint Non weight bearing New lump >2cm
What other signs would place a child in the red category for serious illness?
0-3 months temp >=38 Non blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs Focal seizures Bile stained vomit
What is shock?
Clinical syndrome resulting from a failure of the cardiovascular system leading to poor tissue perfusion
What are the phases of shock?
Compensated - blood flow increased and maldistributed to vital organs
Uncompensated - microvascular perfusion compromised
Irreversible - vital organs not perfumed and irreparable damage caused
What are the most common causes of shock?
Hypovolaemia
Septicaemia
What are the early signs of shock?
Tachycardia Postural hypotension Tachypnoea Cool and mottled Agitated
What are the signs of shock classically seen at diagnosis?
Weak fast pulse Hypotension Tachypnoea and grunting Clammy and blue Decreased GCS
What are the late signs of shock?
Thready pulse Comatose Blue/white appearance Rapid deep breathing - metabolic acidosis Oliguria
What are the 4 types of shock?
Cardiogenic
Hypovolaemic
Distributive
Obstructive
What is cardiogenic shock and what causes it?
Pump failure
CHD
Arrhythmia
Metabolic disturbance
Heart failure
What causes hypovolaemic shock?
Burn
Diarrhoea
GI Bleed
DKA
What causes distributive shock?
Mass vasodilatation
Sepsis
Anaphylaxis
What causes obstructive shock?
Tension pneumothorax
PE
Valve stenosis
How is cardiac output calculated?
Stroke Volume x Heart Rate
How is shock managed?
A-E Approach
Give O2
Elevate legs
Control temperature and glucose
IV 20ml/kg saline
DEPENDS ON CAUSE - treat the cause
How much IV saline should you give to children in shock before moving onto the next step?
40-60ml/kg with no improvement
What is the next step of management for shock after giving fluids?
Elective intubation and ventilation
Start inotropes
Transfer to ICU
What causes anaphylaxis?
Degranulation of mast cells and basophils with systemic release of inflammatory mediators, capillary leak, mucosal oedema and smooth muscle contraction
What central nervous system signs and symptoms are seen in anaphylaxis?
Lightheaded ness Loss of consciousness Confusion Headache Anxiety
What respiratory signs are seen in anaphylaxis?
Shortness of breath
Wheeze/strider
Hoarseness
Cough
What GI symptoms are seen in anaphylaxis?
Painful swallow
Cramp abdominal pain
D&V
What skin signs are seen in anaphylaxis?
Hives
Itchiness
Flushing
What happens to the heart and vasculature in anaphylaxis?
Tachycardia
Low blood pressure
What other things are seen in anaphylaxis?
Swelling of conjunctiva Runny nose Swelling of lips, tongue or throat Pelvic pain Loss of bladder control
How is anaphylaxis treated immediately?
A-E and call for help!
Remove trigger
IM adrenaline 10micrograms/kg
20ml/kg fluids
Repeat every 5 mins if no improvement
100% O2 by face mask
How is anaphylaxis treated once stable?
IV Hydrocortisone
Goes up in same age ranges
25mg, 50mg, 100mg, 200mg
IV Chlorphenamine 1-5 months = 250 micrograms/kg 6 months - 5 years = 2.5mg 6 - 11 years = 5mg 12-17 years = 10mg
Consider salbutamol
What test is done to determine anaphylaxis?
Mast cell tryptase measured at:
1 - At resus
2 - 1-2 hours after
3 - 24 hours after
What are the differentials for anaphylaxis?
Sepsis
Asthma
Panic attack
