Paediatric OSCE's Flashcards
Important points in Paediatric Ataxia and Vertigo?
Most common
Vertigo- benign paroxysmal vertigo of childhood (BPVC)
Ataxia- Post infectious AKA Acute Cerebellar ataxia
Differential
NAI/Trauma
- Head injury, deliberate poisoning, post concussion syndrome
Drugs
- Alcohol, illicit drugs, aspirin, Quinine
Tumours
- Posterior fossa, paraneoplastic encephalopathy
Infections
- Meningioencephalitis, mastoiditis
Inflammatory
- ADEM, labyrinthitis, vestibular neuronitis
Vascular
- Stroke, aneurysm, AVM
Blood pressure
- sepsis, POTS, orthostatic hypotension, arrhythmia, cardiac failure, hypertensive crisis, cushing response (raised ICP)
Ear
- OM/CSOM, FB, Ramsay-Hunt syndrome, impacted wax
Other
- Complex partial seizures, post ictal phase, migraines, psychogenic, visual issues (ie amblyopia)
Time Critical
Head injury, infection (meningoencephalitis, sepsis, mastoiditis), vascular catastrophe
Key points on Hx/Ex
- Altered conscious state
- Signs of raised ICP
- Weakness
- Reduced reflexes
- Signs of head injury
- Focal neurology
- Posterior column loss
- Associated headache
- Behavioural changes
- Photophobia
Acute Cerebellar Ataxia Signs
- Rombergs negative
- No red flags
- Wide based gat and cerebellar signs
- Vibration/joint position preserved
Paediatric Head injury
Signs of raised ICP general
- Diplopia
- Anisocoria
- Cushings response
- Papilloedema
- Abnormal posturing
- New focal neurology/seizures
Neonates raised ICP
- Sunset eyes
- Bulging fontanelle
- Macrocephaly
- Irritability
- <4yo GCS differences (see pic)
Risk factors for severe HI
- Altered GCS/abnormal neurology
- Severe headache
- Repeated vomiting
- BOS or palpable skull fracture
- Non-frontal scalpal haematoma <2y
- Severe mechanism
- Post traumatic seizure
- LOC at scene
- Known bleeding disorder
- VP shunt
- Neurodevelopmental disability
History
- VP shunt, bleeding issues
- fall >1m <2yo, >1.5m >2yo
- Dangerous MVA, struck by high speed object
- circumstances (ie assualt, NAI etc)
- Symptoms pre/post the injury
Definite indications for CTB
- GCS <13 (moderate or worse)
- Focal neuro deficit
- BOS or palpable skull fracture
- Suspected NAI
- Persistent AMS
Mild head injury Mx
- Discharge if GCS 15 + age >6months + non-severe mechanism + No RF’s + no concern of NAI
- If RF’s + mild then observe for 4hrs post injury with 30min neuro obs
- Always give head injury D/C advice
Paediatric C-spine injury
Red Flags on Hx
- Axial load or diving injury (high risk for Jefferson/burst fracture)
- Neurological Symptoms
- Pedestrian/Cyclist hit by car
- Ejection from vehicle
- Fall >3m or twice height
- Kicked/fall from horse
- MVA >60kmh or unrestrained or rollover or head on or death of another passenger
- Predisposing risk for injury
Red Flags on Ex
- Altered GCS
- Concerning neurology (objective motor or anatomical sensory alteration)
- Traumatic torticollis
- Using hands to support head/neck
- Other significant/distracting injuries ie head/chest/abdo/limb trauma
High risk groups
- Trisomy 21, osteogenesis imperfecta, achondroplasia, previous C-spine surgery
C-spine examination
- Provide reassurance and analgesia
- Gently palpate posterior midline from nuchal ridge to T1
- Repeat lateral to midline both sides (minimise neck movement)
- Perform detailed neurological exam
- If no neurology or neck tenderness assess active range with head movement 90 degrees side to side, look up and chin to chest
- If any pain/paraesthesia on movement then cease and replace soft collar
Differences in anatomy
- C2/C3 pseudosubluxation in 40%
- Pre-dental interval normal up to 5mm (adults 3mm)
- Vertebtral bodies more wedge shaped (mimic wedge fracture)
- C2/3 is fulcrum <8 leading to high C-spine injuries (>8 is C5/6)
- Larger head size increases flexion and extension injuries
- Ligamentous injuries more common
- Ossification centres make xrays difficult to interpret
Differences in immobilisation
- Ill fitting collars may trap the chin under them and cause obstruction
- C-spine collars do not fit infants
- Spinal boards and rigid immobilisation raise ICP and decrease TV/respiratory excursion
- Thoracic elevation devices or spinal boards with a hole for the head are used in children <8yo to achieve the neutral position
The shocked neonate
Airway management
- Neck flexion with upper cervical extension
- use a roll under neck to compensate for the enlarged occiput
- usually also need a head rest to get optimal Glabella-Chin plane and external auditory meatus-Sternal notch plane into alignment
- T-piece or neopuff starting 25 PPV (IPAP) and 5 PEEP, RR 40-60, peak pressure of 30 as initial settings
- In a newborn higher initial PPV of 30 (IPAP) unless obviously premature (20-25 IPAP)
Empiric Therapy
- IV ABx (Benpen 60mg/kg, Cefotaxime 50mg/kg)
- Hydrocortisone 4mg/kg IV
- 10% dextrose 2ml/kg (check BSL)
- Alprostadil 20ng/kg/min, max 100ng/kg/min
- Keep warm (resuscitaire with heat lamp on)
- Adrenaline 0.1mcg/kg/min
Special points
- Starting Alprostadil almost mandates intubation as main side effect is apnoea which is dose dependent
- Roughly normal blood pressure is 80 +agex2, so neonate SBP normal is approx 80mmHg
- Normal MAP = approx current gestational age ie 40 weeks corrected age = 40mmHg
Paediatric Vomiting and dehydration
Deficit Replacement
Based on weight loss
- The most accurate determinant of dehydration and fluid replacement
- If pre-morbic and current weight known then calculation = premorbid - current x 1000
- So 20kg child now 18kg (10% loss) = 20-18 = 2, 2kg x 1000mls = 2000mls deficit
- Replace over 24-48hrs
Based on % dehydration
- 5% deficit = 50ml/kg deficit, replacement of 50mlg/kg over 24hrs = approx 2ml/kg/hr
- Deficit replacement given on top of maintenance (ie 4/2/1 rule) and after correction shock with 20ml/kg bolus
- so a 10kg baby would get 6ml/kg/hr (maintenance + deficit) ie 60ml/hr
- Alternative is weight x % deficit x 10mls, then given over 24hrs
- So a 10kg baby would get 10 x 5 x 10 = 500mls, 20mls per hour added
- this equals 40mls maintenance + 20mls/hr deficit = 60mls/hr (same as for previous calculation)
General causes
- Surgical causes/GI obstruction
- Sepsis/CNS infections/HUS
- Raised ICP
- Poisoning/NAI/trauma
- Testicular/ovarian torsions
- Gastro, pneumonia, UTI etc
Neonatal Causes
- Surgical causes (Duodenal atresia, Midgut volvulus)
- Pyloric stenosis! (Caterpillar sign on AXR in pic)
- Inborn errors of metabolism
- CAH
Young child Causes
- Intussusception
- DKA
- GORD
- Food protein induced enterocolitis
Adolescents
- Eating disorders
- Pregnancy
- ETOH and drugs
- Surgical disorders (appendicitis)
- DKA
Red flags
- Severe or localised abdo pain
- Abdominal distension
- Isolated vomiting
- Bilious/green vomiting
- Blood in stool/vomit
- Associated headache or rash
- Feverish if <3months
- Shocked appearing
Risk factors for dehydration
- <1yo, particularly <6months or premature
- Immunocompromised
- Underlying chronic medical issues
- Low birth weight/FTT
- >5 diarrhoeal stools in 24hrs
- Stopped breast feeding whilst sick
- Signs of malnutrition
Discharge criteria
- No signs of worsening
- Passed trial of oral fluids (10ml/kg over an hour usually)
- Alternate diagnoses considered and excluded
- Caregivers comfortable and educated on management at home
Special points
- Babies get volvulus
- Starting to walk (2 or so) get intussusception
- Starting school get appendicitis
Lower limb non-use
Red Flags
- >7 days
- Severe localised joint pain
- Change to bowel/bladder
- complete inability to walk or weight bear
- Nocturnal pain
- Systemic symptoms (fever, night sweats, chills, weight loss, anorexia, lethargy/fatigue)
- Petechiae/purpura/ecchymosis
Good opening statement…
- Although trauma and transient synovitis are the most common causes of limp, less common but significant atraumatic causes need to be considered and ruled out
History
- Red flags
- Screen social issues and NAI
- Birth trauma/issues and development (DDH)
- Trauma/falls
- Pattern of pain (worse with exercise, better with exercise, intermittent, nocturnal etc)
- Functional limitations
- Recent infections
- Systemic symptoms
Exam
- Red flags (petechiae, ecchymosis, wasting)
- Look/Feel/Move the joints of the lower limb
- Assess gait if possible
- Neurovascular assessment of limb
- Assess the abdomen, back/spine and the scrotum
Investigations
- Focussed xray if specific painful point found
- U/S hip if suspicious for septic arthritis
- FBE/CRP for inflammatory disorders and leukaemia
- CK for myositis
- May need Bone scan/MRI to confirm osteomyelitis
Prolonged fever approach
Paediatric PUO definition
- Fever lasting >10 days
- No focus identified
History
- B symptoms (weight loss, night sweats and lumps/bumps)
- Recent travel
- Infectious contacts
- Fever patterns
- Specific symptoms
- New meds (drug reaction)
- Bites/antivenom (serum sickness)
Tests to consider
- Urinalysis
- CXR
- Blood cultures, ASOT
- Lumbar puncture
- Viral PCR
- FBE/CRP/ESR, LFT’s
- Stool cultures
- Bone scan/full body MRI
Causes
- Viral infections (Measles, flu, adenovrius, covid)
- SBI (UTI, pneumonia, TSS, meningitis, osteomyelitis etc)
- Uncommon infections (TB, malaria, fungal infections)
- Autoimmune (kawasakis, JIA)
- Malignancy (leukaemia, lymphoma, Wilms tumour, solid organ tumour)
- Central causes (thalamic dyfsunction)
- Surgical causes (appendix walled off abscess, subphrenic abscess etc)
- Environmental/Drugs (drug reaction)
Kawasakis disease
- Fever >5 days
- Non-purulent bilateral conjunctivitis
- Palm/sole hyperaemia, oedema and/or desquamation
- Cervical lymphadenopathy with node >1.5cm
- Widespread rash that may desquamate later in disease
- Mucosal changes ie strawberry tongue, cracked lips
- Other signs include aseptic meningitis, sterile pyuria etc
- 2mg/kg IVIG, Aspirin 3-5mg/kg
- Steroids in high risk groups
- Consider in infants <6yo with prolonged fever >7days or fever and shock (similar to PIMS-TS)
DDx of Kawasakis
- PIMS-TS
- JIA
- Toxic Shock Syndrome
- SJS/TENS
- Streptococcal scarlet fever
- Adenovirus (rash and conjunctivitis)
Paediatric sepsis
Empiric treatment
- 20ml/kg bolus IV normal saline, with repeat to 40ml/kg
- Can consider more, but start pressors if not responding 40ml/kg
- IV Noradrenaline (warm shock) or Adrenaline (cold shock) at 0.1mcg/kg/min
- Check BGL, give 2ml/kg 10% Dex
- Consider IV Hydrocortisone 4mg/kg for adrenal crisis/insufficiency or Waterhouse-Friedrichsen syndrome
- Aim sats >94% with non-rebreather 15L/min or BVM/T-piece
- Early discussion with PICU/Retrieval
Empiric Antibiotics over 2 months
- Flucloxacillin 50mg/kg IV QID + Ceftriaxone 50mg/kg IV + Gentamicin 7mg/kg IV
- Add Metronidazole 15mg/kg if abdominal source
- Add Vancomycin 15mg/kg if MRSA risk of CVC in situ
- Add Clindamycin 15mg/kg if TSS
- Pip/Taz 100mg/kg if Neutropaenic
Cyanosis approach
Differential Diagnosis
Cardiac causes
- Tetralogy of fallot
- Pulmonary hypertension
- Cyanotic heart disease
Lung causes
- Cystic fibrosis
- Bronchiectasis
- Severe asthma/bronchiolitis
- Neurological issues with respiratory muscle weakness
Other causes
- Airway obstruction (FB, tracheitis, epiglottitis, severe croup)
- Sepsis and circulatory shock (meningitis, TSS etc)
- Central respiratory depression (ICH, NAI, metabolic, coma, tox etc)
- NAI (chest/abdomen/head trauma
- Tox (methhaemglobinaemia, cyanide etc)
- Environmental (cold)
Cyanotic heart lesions (5 T’s)
- Tetralogy of Fallot
- TGA (duct dependent)
- Tricuspid atresia
- Total anomalous pulmonary venous return (Duct dependent)
- Truncus arteriosus
Hypercyanotic spell Mx
- Calm the baby, ie have mum hold them
- Place high flow 02 over face ie NRB at 15L/min
- Knee to chest, either squatting, on back or in mums arms
- Opiates (1.5mcg/kg IN Fent, Morphine 0.1mg/kg IV or IM)
- Gain IV access and give 10ml/kg fluid bolus
At this point you should be discussion with Cardiology/PICU
- Metaraminol 50mcg/kg bolus IV
- Esmolol 500mcg/kg over 1minute then 50mcg/kg infusion
- Emergent airway managment and surgery
Failure to thrive
Acute respiratory distress and Stridor approach
Respiratory distress severity
- See picture
- HR severe tachycardia or bradycardia (pre-terminal)
- Blood pressure very hypertensive or hypotensive (pre-terminal)
Stridor Differentials
- See pic
Neonatal Jaundice
Examination
- Assess for kernicterus (abnormal movements, facial twitching, excessively sleepy, hyper/hypotonia, weak high pitched cry)
- CVS collapse (sepsis, dehydration)
- Organomegaly
- Trauma, bleeding, haematomas
- Hypertonia, seizures
History
- Hydration and feeding (breast vs formula feeding)
- Pee/poo colour
- Maternal screening, baby screening (heel prick) and ABO status
- Birth trauma/instrumentation
- FHx spherocytosis/G6PD, thyroid issues, previous jaundice, family background
- Poor weight gain or weight loss >10% of birth weight in 1st week
Red flags
- Unwell baby
- Fevers and jaundice
- Dark urine and pale stools (obstructive cause)
- Jaundice in 1st 24hrs
Early Onset <24hrs
- Always pathological
- Sepsis and haemolysis (ie ABO incompatability) main causes
24hrs to 14 days
More benign- Physiologic, breast milk induced, haematoma/bruising breakdown (ie cephalhaematoma)
Serious- Haemolysis, sepsis, dehydration
Prolonged (>14 days)
Benign- Breast mild jaundice
Serious- Sepsis, haemolysis, dehydration and hypothyroidism
Conjugated (at any point)
- >10% conjugated bilirubin
- Biliary atresia is top differential, surgical emergency!
- Metabolic syndromes (ie Alpha 1 antitrypsin)
- Neonatal hepatitis (ie TORCH
Neonatal sepsis
Mother Risk Factors
- Maternal Fever
- Pre-term delivery
- PROM/PPROM >18hrs and chorioamnionitis
- GBS or STD colonization
- Obstetric complications and instrumentation (late onset sepsis)
Infant risk factors
- Foetal distress and/or Mec liquor
- APGAR score <6
- Congenital abnormalities
- <37 weeks gestation
- ATSI background
- Low birth weight
Exam findings
- Lethargy, poor feeding
- tachypnoea/apnoea
- Tachy/bradycardia
- Hypotension, prolonged CRT
- Signs of raised ICP, seizures
- Non-blanching rash
- Jaundice, Hepatomegaly
- Hyper/hypothermia
- Cyanosis/pallor
Empiric Antibiotics
- Benpen 60mg/kg, Cefotaxime 50mg/kg
- Aciclovir 20mg/kg if HSV/VZV suspected or encephalitis (sleepy, seizures, abnormal behaviour)
- Gentamicin 5mg/kg (7.5 if >1 week old) and Metronidazole 15mg/kg if abdominal
- Flucloxacillin if S. aureus suspected (ie skin or umbilicus infection)
TORCH
- Toxoplasmosis
- Other (Syphilis, Parvovirus, VZV)
- Rubella
- CMV
- HSV and Hep B
Most common (GELS)
GBS (G)
- fulminant <7 days, but can occur up to 3 months
- RFs are PROM, intrapartum fever, chorioamnionitis, prem <37/40
E. coli (E)
- usually early, but at risk up to 3 months
- Same risks as GBS
Listeria monocytogenes (L)
- immunocompromised mother, meats and cheese
Strep and Staph (S)
- Staph in umbilical infection
Non-infectious causes fever
- Environmental exposure
- CAH
- Thyroid disease
- CNS insult and seizures
- Neonatal abstinence syndrome
- Dehydration
Maternal Chickenpox exposure
- If 5 days before 2 days after delivery give ZIG to baby as prophylaxis
- If develops symptoms of VZV then give IV aciclovir 20mg/kg
The crying baby
Initial assessment priorities
- Life threats and time critical conditions (ie sepsis)
- pathological conditions (ie cows milk allergy)
- Parental mental health and NAI risk
- Common conditions
Red Flags
- Sudden onset
- Evidence of parental post natal depression
Post natal depression screening
- Have you thought about harming yourself?
- Have you thought about harming your baby?
- Supports in community?
- Domestic violence screen
- PHx of mental health disorders, drug use, medications, alcohol
Acute onset DDx
- Raised ICP
- NAI, clavicle fracture
- Incarcerated inguinal hernia
- Volvulus or obstruction
- Hair tourniquet
- corneal FB or abrasion
- UTI/Pyelonephritis
Common causes DDx
Excessive tiredness
- awake for too long or total sleep needs not being met by >1hr
Excessive hunger
- usually associated with poor weight gain
Non-IGE cow milk/soy protein allergy - vomiting, diarrhoea with blood and mucous, poor weight gain, eczema, can be transferred from mothers milk if excessive consumption
Lactose malabsorption
- frothy watery diarrhoea with perianal excoriation
GORD
- Uncommon
Constipation
Rarer causes DDx
Neonatal abstinence syndrome
- Maternal drug use with withdrawal symptoms in neonate
Drug ingestion
- NAI vs misinformation vs accidental
Testicular/Ovarian torsion
Cardiac issues
- CHD, neonatal SVT
Glaucoma
- tearing, photophobia
Physiological Crying and “colic”
- AKA purple crying
- Infants cry the most in 1st 3 months
- Normally babies cry on average for 2hrs per day
- Colic is >3hrs per day, 3 or more days a week, <3 months age, no other cause found
- Common, baby not sick, usually resolved by 3-4 months age, they are not doing anything wrong
Treatment of colic
- Parents take breaks during crying (ie placing in cribs, another adult looks after them etc)
- Feeding changes, adequate burping
- Pacifier, rocking, taking a ride in car or walker, warm bath
- Minimizing external stimuli
- Hip healthy swaddling
Special points
- Excessive crying is a strong risk factor for NAI, specifically shaken baby syndrome
Neonatal SVT/Tachycardia
Differentials
- Primary AVRT most common cause ie WPW in neonates
- Rapid sinus tach (trauma, sepsis, dehydration, bleeding etc)
- AVNRT (more common in adolescents)
- Atrial flutter (common in neonates)
- VT (>90msecs is cut off for wide complex in neonates)
- Junctional ectopic tachycardia post cardiac surgery
- Atrial tachycardia
Causes of SVT
- fever and dehydration can precipitate
- Endocrine (adrenal crisis, DKA and thyrotoxicosis)
- Cardiomyopathy
- Electrolyte abnormalities
- Accidental drug ingestion
- Trauma/NAI (actually rapid sinus tachycardia)
Treatment
Vagal Maneuvres
- Apply bag containing ice water to the face above the mouth/nostrils for 15-30secs
- Can be performed if unstable whilst setting up for drugs/cardioversion, but should not delay these actions
Adenosine
- 0.1mg/kg > 0.2 > 0.3
DC synced cardioversion
- 1j/kg > 2j/kg > 4j/kg
Alternatives
Verapamil
- NOT <1 year, profound hypotension
- 0.1mg/kg
Amiodarone
- IV 5mg/kg, side effects more pronounced in children
Beta Blockers
- Esmolol, loading 100mcg/kg then 25mcg/kg/min infusion
Procainamide
- IV 10-15mg/kg, minimal availability
An approach to the BRUE (Brief, resolved unexplained event)?
Definition
- An event characterised by a marked change in tone, colour, breathing or level of responsiveness; followed by a return to baseline state with no medical cause found
- Diagnosis of exclusion
- Thought to be due to exaggerated airway reflexes in setting of feeding, reflux or airway secretions
Criteria
- <12 months
- <1 minutes
- sudden onset > return to baseline
- 1 or more of cyanosis, pallor, altered breathing, altered GCS, altered tone (hyper or hypo)
- No medical cause found
Low Risk
- No concerning features
- Age >60 days
- born >32 weeks and >45 weeks corrected gestational age
- first event
- <1 minute
- No CPR by trained health care professional
Investigations and Management
- Nil for low risk
- ECG (QT interval)
- FBE/UEC and BSL
- Viral/Pertussis swabs
- Others as indicated by exam or history
- Generally always needs admission for observation/parental concern
Red Flags Hx
- FHx or risk factors for NAI
- Recent injury
- Exposure or symptoms of infections
- BRUE or sudden unexplained death in a sibling
- Preceding unwellness in days prior
- Administration/access to medication
- Birth/antenatal issues, developmental delay or congenital anomalies
- Episodic vomiting or lethargy
- Feeding history and issues
NAI screening
- Must touch on this
- Bonding with the child?
- Feeling depressed?
- Supports at home? Feel safe?
- Any thoughts of harm towards the child?
- Has anyone else had access to your child?
Red Flags Ex
- Bruising, bleeding or injury (TEN 4 FACES)
- Organomegaly
- Fever or toxic appearance
- Decreased pulses or murmur
- Respiratory distress
- Abdominal distension/vomiting
- Abnormal tone, raised ICP
Important DDx (MISFITS)
- Infection (pertussis, pneumonia, meningitis etc)
- FB inhalation
- Congenital HD, long QT or other arrhythmia (ie SVT)
- NAI, accidental drug ingestion
- Metabolic derangment (low BSL, electrolytes, inborn error)
- intussusception, testicular or ovarian torsion
- Seizures
Special points
- No increased risk of SIDS
What is the WETFLAG’s mnemonic for paediatric resuscitation?
WETFLAG
Weight
- [(Age +4) x 2] for 5 and below
- age x3 + 7 for 6 and above
Electricity
- 4j/kg
Tube
- Age/4 +4 without cuff
- Age/4 + 3.5 for cuffed
Fluid
- 20ml/kg bolus
Lorazepam (midazolam in aus)
- 0.15mg/kg
Adrenaline
- 10mcg/kg
Glucose
- 2mls/kg of 10% dextrose
Paediatric and neonatal seizures
Seizure mimics neonates
- Jitteriness/Rigors
- Benign neonatal sleep myoclonus
- Non-epileptic apnoea
- Opisthotonus
- Normal movement
- Cardiac disorders
Seizure mimics older children
- Breath holding
- Rigors or chills
- Syncope (myoclonic jerks)
- Tics or stereotyping
- BPPV in children
- Migraine variants
- Chorea (rheumatic fever) + athetosis
Neonatal Seizures causes
- HIE
- CNS infection
- Trauma/intracranial bleed
- Drug withdrawal
- Drug intoxication (accidental/NAI)
- metabolic derangements and inborn errors metabolism
Neonatal Seizure Mx Differences
- Phenobarbitone 20mg/kg IV is first line (not midazolam)
- Consider Pyridoxine 100mg IV
- IV Acyclovir 20mg/kg for HSV infection, Cefotaxime 50mg/kg and Benpen IV 60mg/kg
- Check and correct low Mag/Na+/BSL and hypocalcaemia
- Consider hydrocortisone 4mg/kg for CAH Addisonian crisis
Levetiracetam vs Phenytoin
- Keppra given over 5mins, fewer drug interactions, more compatible with IV fluids and lower risk of adverse events
- Phenytoin over 20-30mins, resource intensive, many side effects, death from rapid dosing
Key points on history
- Previous seizures/epilepsy including medications and previous status
- Duration pre-hospital
- Neurological comorbidities (VP shunts, brain abnormalities)
- Reanl failure (hypertensive encephalopathy, electrolytes)
- Endocrinopathies (electrolytes)
- Inborn erros metabolism (ICP, ammonia, specific managment)
- Trauma, infective symptoms, exposure to medications, FHX
Paediatric CNS infections
Early signs meningococcus
- Leg pain and poor ambulation (peripheral ischaemia)
- Myalgia out of proportion
- Early maculopapular rash
- Lethargy and prolonged CRT
- Cool peripheries, mottling
CSF signs bacterial meningitis
- CSF glucose <2.2
- CSF/blood glucose ration <0.4
- Elevated WCC’s with predominant neutrophils
- Elevated protein
- PCR for most bacterial causes available, culture is definitive
Steroids for Meningitis?
- Predominant effect is reducing deafness in HiB infection
- Still strongly recommended over 2 months age
- 0.15mg/kg Dex QID max 10mg
Neonatal vs Paediatric
- GELS organisms + HSV most common in neonates
- Much more common in neonate, uncommon past 3 months
- Paeds Strep Pneumo and Neisseria meningitidis
- Paeds most common viruses enterovirus, parechovirus and coxsackie virus
Features of HSV CNS infection
- Focal seizures
- Focal neurological signs
- Predominant CSF lymphocytes
- HSV vesicles on skin/mucosa
- Altered mental status
Risk factors for meningitis
- Neurosurgical procedures (VP shunt, cochlear implant etc)
- Not vaccinated
- Immunosuppression
- Recent contact with meningitis case or HSV cold sores
- Overseas travel
- GBS colonised mother (neonates)
Chemoprophylaxis
- Household contacts
- Nurses spending >6hrs with patient
- Direct contact with nasopharyngeal secretions without appropriate PPE (intubation, mouth to mouth resus etc)
- Always monitor the local public health unit
Causes of altered consciousness in paediatrics?
Adolescent in emergency screening?
Main complaint
- Screen for red flags (ie if presenting with abdo pain, headache etc)
- Exclude organic life threats
- Short focussed history
HEADS screening
- see pictures
Sexual health
- focussed sexual history
- assault, STI’s, risks
Social history
- Parents/carers
- Risks for abuse
- Screen for occult homelessness
Eating disorders
- Particularly important in adolescent females
- binge/purge, laxatives, weight loss, medication use
- Palpitations, syncope etc
Examination
- Focussed examination of presenting complaint
- Look for sequelae of drug use, eating disorders and abuse
Management
- Based on main complaint
- Low threshold to admit and engage social work +/- mental health +/- specialties
Sickle Cell Disease approach?
Acute chest syndrome basics
- Vaso-occlusive crisis in the lungs
- New opacity on Xray combined with fever and respiratory symptoms including chest pain
- More prone to atypical infections (chlamydia, mycoplasma, salmonella)
- The commonest cause of death in sickle cell patients
Acute chest syndrome precipitants - Infection (pneumonia, sepsis)
- Sedation (surgery, opioids etc)
- Dehydration
- Hypoxia (asthma, pulmonary oedema, atelectasis etc)
- Pain (other VO crisis, injury etc)
Acute Chest syndrome DDx
- DDx Pneumonia/sepsis, MI, PE, decompensated chronic cor pulmonale, splenic sequestration, line infection (Port in situ)
Acute Chest Syndrome Mx
- See picture
- Consider bronchodilators if possible underlying asthma
- Cover for atypicals (azithromycin and Ceftriaxone)
Vaso-Occlusive Crises
Acute splenic sequestration
- Defined as splenic enlargement with acute drop 20g/L
- Transfuse aiming for Hb 50-60 and haemodynamic stability
- 10-20ml/kg saline bolus while awaiting blood
- Raising Hb too quickly can cause hyperviscosity and stroke (not more than 30g/L rise)
- Cover with antis
Priapism
- Early Uro/Haem contact
- 02, analgesia, IV fluids
- Empty bladder
- Warm pack, take a shower and do some light exercise
- May need exchange transfusion
Aplastic crisis
- Acutely unwell, drop in Hb and massively reduced reticulocytes (<1%), often from Parvovirus
- IV antis
- Maintain hydration
- Aim Hb 50-60g/L
Stroke
- Treat as per stroke normally but with caveats
- Transfuse if needed to 50-60g/L
- NO CONTRAST (worsens viscosity)
- May need red cell exchange
Down Syndrome Approach
ECG changes
- Superior axis (AVL and AVR up, all else down) if AVSD present (see ECG attached)
- RAD (RVH with pHTN)
Common Issues
- Epilepsy (8%)
- 50% have congenital heart diease! AVSD/AVCD is most common and varies in severity
- Atlantoaxial subluxation (risk factor for intubation)
- Leukaemia (1/300 chance, can present atypically, harder to treat)
- Relative immune deficiency
- Diabetes mellitus (1%)
- Hirschsprungs (2%) and Duodenal stensosis/atresia
- Hearing loss mainly from recurrent OM and CSOM
- Glaucoma and cataracts
- Coeliac disease
Down syndrome intubation
- Atlantoaxial subluxation
- pHTN and cardiac defects
- Larger tongues
- Otherwise smaller airways
- OSA
- Hypotonia with early desaturation
- Excessive secretions, need more suctioning than usual
Non-Accidental Injury approach and injury patterns?
Risk Factors for NAI
- Age <1
- Prematurity
- Mental/physical disability
- Poor social supports
- DV at home
- FHx mental health issues or substance abuse
Bucket Handle (metaphyseal corner fractures)
- <24 months
- Often in the proximal tibia but can occur in other parts of the limbs
- Usually from shaking mechanism with shearing forces
Ten 4 Faces(p)
- Bruising in children <4yrs
- See picture
Examination
- A/B/C approach
- Look for life threats first
- Consider co-existent abdominal injuries and intracranial injuries
- Ophthalmoscopy for retinal haemorrhages (ophthalmologist)
- Consider CT brain and abdomen, skeletal survery, ultrasound etc
Management
- Always screen for other injuries
- Look at previous imaging if available (ie CXR for previous pneumonia etc)
- Discussion with paediatrics and VFPMS, if indicated after this needs referral to DHS
- Police and child protection
- Skeletal survey +/- bone scan
- Targeted CT/MRI as needed
Governance
- Missed or near-miss NAI should be brought up at M&M and consider a VHIMS/SAC 1 or 2 report
- Ie previously missed Xray findings, particularly if missed by radiology
Differentials for NAI
- osteogenesis imperfecta
- Menkes disease
- Ehlers-Danlos syndrome
- Congenital insensitivity to pain
- Alternative medicine and practices (cupping, medications etc)
Neonatal hypoglycaemia
Definitiion
- BGL < 3.3 for paeds
- BGL <2.6 neonates
Accelerated starvation
- The most common cause in paeds >2yo
- Period of fasting usually in context of mild illness
- Hypoglycaemia with associated ketonaemia and ketonuria
- Resolves with feeding
Other differentials
- see picture
History Red flags
- Anxiety, sweating
- Hypothermia, confusion, coma, seizures, irritability, lethargy (symptoms of severe hypoBGL)
- in neonates <48hrs (apnoea, jitteriness, hypotonia, poor feeding, high pitched cry)
Extended history
- Previous hypoglycaemia episodes
- seizures
- GI surgery or disorders
- Dietary intake and type (inadequate intake, food allergies)
- Toxin exposure (alcohol, sulfonylureas, BB’s, aspirin etc)
- Screen for sepsis/shock/trauma
- FHx cosanguinity, hormonal deficiencies, hyperinsulinism, unexplained infant deaths
Exam
- A/B/C
- Fevers and hypothermia
- Dysmorphic
- Hepatomegaly and hypotonia (inborn error of metabolism)
Treatment
- If conscious give glucose gel (0.2gm/kg up to 15gm)
- 2ml/kg of 10% glucose IV
- IM glucagon 0.1mg/kg or 1 unit if >25kg’s
- Collapsed neonate protocol if appropriate (Fluids, ABX, glucose, hydrocort, prostaglandin)
Investigations
- Targeted to specific cause (ie sepsis, trauma etc)
- BSL and ketones
- Lactate, ammonia (IEM)
- VBG/electrolytes (adrenal crisis)
- Cortisol, insulin, c-peptide
- Fatty acids, carnitine etc
Paeds Abdominal pain approach?
Infants DDx
- Volvulus
- NEC (neonates)
- Colic
- Intussusception
- Hirschsprungs
- Incarcerated hernia
Paeds DDx
- intussusception
- Constipation
- Gastro
- HSP
- Pancreatitis
- Sickle cell crisis
- Pneumonia
Adolescents DDx
- Appendicitis
- Pregnancy
- STI and UTI and PID
- ovarian/testicular torsion
- Gastritis
- Psychochenic/Munchausen
- SBO
- Billiary tract disease
Age independent DDx
- NAI
- Tox ingestion
- Trauma
- DKA
Appendicits on ultrasound
- See pic
- Good for ruling in but can’t rule rule out appendicitis
- CT scan >95% but radiation risk
Paediatric Appendicitis Score
- 0-3 is low risk (discharge and safety netting)
- 4-6 is intermediate risk (scans, bloods and observation)
- Score 7 or higher is high risk (admit surgery, likely theatre)
- All points are 1 marks, except those with asterisk are 2 marks
Scoring points on PAS
- Tenderness to RLQ *
- RLQ Pain to cough, percussion or hopping *
- Pain migrates to RLQ
- Anorexia
- Fever (>38C)
- N/V
- WBC >10,000
- Neuts (ANC) >7500
Anorexia Nervosa approach?
Indications for psychiatric vs Medical admission
- See pic
- eGFR <60 or dropping (med)
- Albumin mildly low (Psych) or <30 (medical)
- LFT’s mildly deranged (Psych) or ALT/AST > 500 (Med)
- Neuts <1.5 (psych) or <1.0 (med)
- SI/self harm or significant distress are indications for psych admit
Life threats
- Hypovolaemic shock
- Cardiac failure, cardiogenic and arrhythmogenic shock
- Septic shock (relative immunosuppression)
- PE with obstructive shock
- Booerhaves syndromes
- Respiratory failure from muscle atrophy or refeeding syndrome
- Seizures/encephalopathy from hypoglycaemia and metabolic derangement
- Severe anaemia with high output cardiac failure
- Acute liver failure, severe electrolyte derangement
DDx for Cachexia
- Eating disorders
- Malignancies
- Endocrine disorders (hyperthyroid, diabetes mellitus)
- Malabsorption (coeliac, short gut syndrome etc)
- Inflammatory bowel disease (any chronic inflammation)
- Chronic infections (TB most common)
History
- SI and self harm, psychotic/mania and depression symptoms
- Weight loss amount (current and pre-morbid), percentage and time frame
- Menarche and menses Hx
- HEADSS screen
- heart failure symptoms, syncope, palpitations, light headedness
- B symptoms, thyroid symptoms, fevers, lumps/bumps
- FHx AN and mental health
Exam
- Weight, height, BMI
- Postural BPs and HR
- Temp (hypothermic)
- cachexia, oedema, murmurs, heart failure signs
Investigations
- BSL, VBG
- ECG
- FBE (anaemia)
- UEC/CMP (hypoelectrolytes and risk of re-feeding)
- LFT’s (High ALT/AST, low alb)
- Nutritional (ADEK, B12, folate, zinc)
- BHCG if female
- If first presentation then coeliac, ESR and TFT’s)
Treatment
- Adress ABC’s
- slow correction of all electrolytes and BSL as rapid replacement may precipitate arrhythmias and refeeding syndrome
- IV or oral replacement Mag + K + Ca + Po4
- Postural hypotension give fluid aiming BP <15mmHg drop
- IV thiamine 300mg
- Admit med/psych, may need cardiac monitoring
- May need NG
- Atropine for unstable bradycardia, myocardium irritable and other inotropes may cause malignant arrhythmias
