Paediatric emergency medicine Flashcards
when should a parent send in their child to ED to get their plaster cast checked?
the cast is cracked, soft, loose or tight, or has rough edges that hurt
you are worried that an object has been pushed inside the cast
there is an offensive smell or ooze coming from the cast
there is increasing pain–> signs of compartment syndrome
what are some general practice principles about plaster cast care?
- keep dry as much as possible
- do not stick things into the cast to scratch
- try not to bend it in the first 24hrs as it hardens
- do not remove the inside fluffy layer of the cast- exposing the skin directly to the plaster
what consists of a full septic work up for an unwell neonate?
FBE, blood culture, urine culture ± CXR (if respiratory symptoms or signs) ± LP
what should we do for a child with impaired conscious state, focal neurological signs or who is haemodynamically unstable?
working diagnosis= meningitis/encephalitis
so immediate management with IV or IM ceftriaxone or benzylpenicillin
+/- dexamethasone
what are some examination features of meningitis in a child?
In infants, the fontanelle may be full
Neck stiffness may or may not be present (not a reliable sign in young children)
A purpuric rash is suggestive of meningococcal septicaemia
Kernig’s sign: hip flexion with an extended knee causes pain in the back and legs
CSF shunts, spinal and cranial abnormalities (eg dermal sinuses) which may have predisposed a child to meningitis
Signs of encephalitis: altered conscious state, focal neurological signs
what are some follow up practice points for young children with diagnosed bacterial meningitis?
All children with bacterial meningitis should have a formal audiology assessment 6-8 weeks after discharge (earlier if there are concerns regarding hearing).
Neurodevelopmental progress should be monitored in outpatients.
acute management of open fracture?
• Fast the patient
• Morphine IV
• Tetanus status- ADT? Or Tetanus antibodies?
• IV antibiotics
• Immobilise fracture for pain management
Direct pressure on the bleeding vessel with blood loss apparent.
what is the significance of stridor/wheeze in a burns patient?
indicates where the injury is in the airway;
stridor= high (extrathoracic obstruction), wheeze = low (intrathoracic obstruction)
what management might we consider for a circumferential chest burn and why?
what about a circumferential burn for a limb like a leg or an arm?
an escharotomy; if its 3rd degree full thickness burn
this involves cutting the burned skin as it is restricting their ventilation
again consider escharotomy if you feel the burn is acting like a torniquet around the limb
how might we neutrally align the cervical spine of a child?
place 1-2 towels beneath buttock or back
this is because the child’s occiput is larger than the adult
what manoeuvre do we use to open a child’s airway?
jaw thrust (not chin lift or head tilt)
a child comes into ED and you suspect gastroenteritis. the child is unwell looking and dehydrated. you commence fluid resuscitation. 24 hrs later, the child is still unwell. what do you do?
immediate surgical referral to rule out appendicitis and intussusception
what is glue used for wound healing in ED?
glue= dermabond= cyanoacrylate= tissue adhesive that replaces sutures for small superficial lacerations
how is glue applied to a wound?
- LA if required
- Clean wound with n.saline
- bring wound edges together
- break vial and apply glue over (NOT INTO) the wound line
- Let dry for 2mins
- Apply second layer +/- steristrips if required
- let dry again for 2mins
- advise no picking at the glue adhesive, it will fall off itself. No scrubbing or applying lotions to the glue- pat dry if wet.
at what age are you seriously concerned about a child with a fever and what do you do?
less than 3 months old (but really now guidelines say less than 1 month) with a fever
bring them straight into the ED for a full septic work up
what is always abnormal in the CSF of a patient with suspected bacterial meningitis regardless of age?
presence of polymorphs/neutrophils is always abnormal
A girl is BIBA to ED with hypotension, fever and diffuse erythroderma and altered conscious state; paramedics report they found and removed a retained tampon. you automatically think toxic shock syndrome. what is your acute management?
- If the tampon had not been removed, remove it.
- Drain any abscesses.
- Aggressive fluid resuscitation and transfer to ICU.
- Empiric antibiotics initially then clindamycin + penicillin (consider vancomycin or flucloxacillin for staph)
- Surgical debridement.
how do we diagnose staphyloccocal scalded skin syndrome?
clinical diagnosis only
Painful erythema in flexures/buttocks (intertriginous areas)
Also in perioral area
Short blistering phase
Fever
seen in NEONATES/young children
what is the management of HSP in ED?
- Rule out bleeding disorders, sepsis, meningoccocal disease
- Check urine, UEC
- Give steroids for acute management
- Usually self-limiting without much complication; supportive care such as analgesia
- Organise renal follow up and monitoring
Tell me your management of suspected DKA?
- Secure airway, consider Ng tube to avoid aspiration (ABCDE- resuscitation)
Obtain IV access x 2; take blood and blood gas- look for bgl, ph, blood/urinary ketones + UEC, wcc
If bgl greater than 11.1 mmol/l, ph low, ketones present; biochemical dx of DKA.
- Supportive management eg 02, cardiac monitoring if required
- Determine level of dehydration; if moderate/severe; commence fluid bolus therapy of 0.9% normal saline 10ml/kg and reassess. If mild, may not need fluid bolus.
- IV insulin + potassium (check k+ levels first prior to replacing)
- Ongoing monitoring- blood gas, UEC blood glucose
Watch out for hypoglycaemia and hyponatremia
switch to SC insulin when appropriate and change fluids to normal saline + 5% dextrose when BGL reaches between 12-15mmol/l
what is the dose of adrenaline for resuscitation of a paediatric patient?
10mcg/kg
what are the hand techniques used when administering CPR in a neonate, young child and older child
With large children use the “heel” of one hand with the other superimposed.
For small children use the heel of one hand
For infants use two fingers.
For newborn infants the best technique is a two-handed hold in which both thumbs compress the sternum.
what are the complications of untreated nephrotic syndrome?
hypovolemia
infection
thrombosis
how do we manage confirmed first presentation of nephrotic syndrome in a child?
- admit to hospital
- oedema management- frusemide, fluid restriction etc
- prophylactic antibiotics
- prednisolone based on BSA
- family education regarding relapses and immunisations whilst on steroid therapy
- review with nephrology
in prednisolone resistant cases of nephrotic syndrome, what medication might you try?
cyclophosphamide
You (as a community/rural doctor) refer a child to the RCH and they require acute medical ICU management during their transport. what transport service do you call?
PIPER
paediatric infant perinatal emergency retrieval
what antibiotics do we give for necrotitising fasciitis?
flucloxacillin
clindamycin
what antibiotics do we use for a child with meningitic symptoms and possible encephalitis? lets say the child is older than 2 yrs old.
ceftriaxone + dexamethasone
+ ACICLOVIR
which kids need to be medically assessed in the case of suspected paracetamol overdose?
- Acute ingestion of > 200mg/kg
- Ingestion of unknown quantity
- Repeated supratherapeutic ingestion of > 100mg/kg/day
what are some clinical features of paracetamol toxicity in a child?
RUQ pain or tenderness, nausea, vomiting
what ix should we order for a child who we suspect has had a paracetamol overdose?
LFTs
UEC- can cause acute kidney injury
serum paracetamol levels!- determines whether NAC should be given
what key question on history should be asked in the case of a suspected acute paracetamol overdose in a child?
how long ago did the child ingest the paracetamol?
if > 8 hrs, warrants n-acetylcysteine
a child comes into ED fitting > 5mins and it does NOT appear to be a febrile convulsion. What is your line of management?
DRSABCD- call for help
- Support airway and breathing, provide O2 with mask
- Gain IV access- check electrolytes and BSL (bedside finger prick)
- If low BSL–> manage as for hypoglycaemia
- Give buccal benzodiazepine like midazolam or diazepam
- repeat benzo after 5mins if still fitting
- for refractive convulsions, give phenytoin
- senior assistance and intubation may be required in the case the above approach does not work
what are the clinical features of epiglottitis?
Absent cough with low pitched expiratory stridor (often snoring) and drooling suggests epiglottitis.
what is your management of a child with acute abdo pain?
ABC
Early referral of patients with possible diagnoses requiring surgical management.
Fluid resuscitation may be required (initial bolus 20ml/kg normal saline)
Establish and maintain intravenous access in sick children.
Measure electrolytes and blood sugar if the patient appears dehydrated
Keep patients fasting if surgical cause suspected
Provide adequate analgesia – iv morphine may be required or intranasal fentanyl as initial analgesia in severe pain (see Analgesia and sedation)
Consider a nasogastric tube if bowel obstruction suspected
Consider IV antibiotics in surgical causes (discuss with surgeon first)
Other investigations and management will be guided by clinical findings
tell me the clinical presentation of intussuception
The child appears to have intermittent pain, which is colicky, severe and may be associated with the child drawing up the legs.
• Episodes typically occur 2‐3 times/hour and may increase over the next 12‐24 hours.
• During these episodes of crying the child may look pale. Note that many other causes of infant crying are associated with facial
redness rather than pallor.
• Pallor and lethargy may be the predominant presenting signs, but may be persistent rather than episodic, and in some the
crying episodes may not be very vigorous.
• Vomiting is usually a prominent feature (but bile stained vomiting is a late sign).
• Bowel motions may contain blood and/or mucus. The classic red currant jelly stool is a late sign.
describe key ix and mx considerations for suspected intussuception?
AXR looking for bowel obstruction/perforation
U/S- target sign- diagnostic
manage fluid status- resus as required
NGT tube to drain free fluid
IV cefazolin/metronidazole
Air enema reduction–> diagnostic and therapeutic
what is your management of bilious vomiting in a neonate?
- Admit the infant
- Call the neonatologist and contact paed surgical registrar
- Do your ABC. Keep airway patent, supply O2 mask and establish IV access
- Check BSL and correct glucose if required.
- Keep baby warm
- Take bloods: FBE, UEC, LFTs, ABG, cross match, coags
- Order AXR erect and supine + upper GI contrast study
- Insert oral gastric tube and commence IV fluids.
- Keep nil by mouth and correct any abnormal electolytes.
- Administer IV antibiotics if required.
Keep the parents updated and depending on the pathology (e.g. malrotation) advise them of the treatment options/plan.
