Paediatrics: A-E Flashcards
what is the 3 minute toolkit?
top to toe examination and physiology assessment
what does ABCDENTTT, DEFG stand for?
- Airways
- Breathing
- Circulation
- Disability (neuro)
- Ears, nose + throat examination
- Temperature
- Tummy
DEFG (don’t ever forget glucose)
3 minute toolkit overview: what do you look for for A
airway
- secretions
- stridor
- foreign body
3 minute toolkit overview: What do you look for for B
breathing (effort, efficacy, effect)
- RR
- Recession/accessory muscle use
- Oxygen saturation
- Auscaltation
3 minute toolkit overview: what do you look for for C?
Circulation
- Colour (e.g. pale, mottled)
- HR
- Cap Refill
- Temperature of hand and feet
3 minute toolkit overview: What do you look for for D?
Disability (neuro)
- Pupils
- Limb tone + movement
- AVPU score/GCS
airway assessment: child has reduced consciousness levels, why test gag reflex? what do you do?
oropharyngeal airway: if tolerated => child not protecting airway => jaw thrust + call anaesthetist
do children look better or worse than adults when hypoxic?
better
- children can be close to decompoenstaion when looking well
what oxy sats should ac child have
> 96%
oxy sats significant hypoxia ? worrying hypoxia?
sig: <94%
worrying: < 90%
at what oxy sats might a child start showing signs of cyanosis?
<85%
very late!
what does mottling of the skin suggest?
poor perfusion
what pulse should you use to get pulse rate?
radial pulse
(brachial in baby)
(can use pulse oximeter)
what is normal cap refill time?
<2 sec
where do you test cap refill?
- Central (sternum)
- Peripheral (fingers, toes, hands, feet)
what could cool peripheries suggest?
peripheral vasoconstriction due to sepsis, dehydrations
When should you measure BP of a child?
only measure if concerned
(drowsy or sick child)
(do it at the end of examination)
When might you get sluggish pupil responses?
- post fit
- drug overdose
When might you get assymetrical pupil responses?
space occupying lesion (extra/subdural haemorrhage)
When might a child be drowsy?
- Post fit
- High temp
When should you do the ENT assessment
leave till the end
How do you position patient to do ears bit of ENT?
sit child sideways on parent lap and hold tight, hold baby arms and head still
How to you position patient to do throat bit of ENT?
sit baby facing you on parent lap, hold baby arms and head still
Where do you measure temperature ?
timpanic (usually better)
axillary strip (recommended in babies)
How should child be positioned for tummy assessment?
best lying flat on bed but can do on parent lap
What do you also have do check in boys for tummy assessment? why?
check for testicular tosion
- can cause abdo pain
what could cause hypoglycaemia in children?
- recent low calorie intake
- alcohol consumption
What is one of most common causes for young children to go to doctor?
difficulty in breathing
what infections most commonly cause difficulty in breathing?
- strep. Pneumonia
- haemophluis influenza
- pertussis
- Mycoplasma
- Influenza virus
commonest causes of brethlessness (4)
- Asthma
- bronchiolitis
- Pneumonia
- croup
What main symptoms does asthma cause?
- Breathlessness
- Coughing
- Wheezing
asthma pathophysiology?
hyperactive airways => constrict + secret mucus => narrow airways => wheezing
what is wheeze? how does it affect breathing?
high pitched sound on expiration
- prolonged expiratory phase
what can trigger wheeze?
- Infection (often viral)
- Cigarette smoke
- Exercise
- Dust
- Pollen
What is Croup? which bit of airway?
Viral infection of upper airway => inflam of airway => airway obstruction + breathing difficulty => barking cough + hoarse voice
what will you see on observation of a child with airway obstruction?
intercostal recession
subcostal recession
sternal recession
tracheal tug
What does the turbulent airflow in croup cause? sign
stridor (inspiratory of expiratory) (harsh sound)
- gets louder as narrowing worsens
why do you need to keep a child with croup calm?
if tired (exhausting the kid) => resp failure (so make sure child relaxed)
croup mangement ?
- responded well cos steroids (oral dexamethosome or prednisolone)
- If severe: nebuliser adrenaline (buys you time while steroids work)
What are the main symtoms of bronchiolitis ?
- sob
- wheezing
- wheezy cough
- runny nose
- mild temp
in what age group is croup most common in
toddlers (6 month - 3 yrs (most common at 1 yr))
in what age group is bronichiolits most common in?
1 month - 2 yr
bronchiolitis most common aetiology?
viral cause (often resp syncytial virus)
Where in airways is affected in bronchiolitis ? what kind of cough ?
infects lower airways => secretions => wet cough
bronchiolitis management ?
no specific treatment
- May need to be admitted if hypoxic
generally is viral or bacterial pneumonia worse?
- Viral (self limiting)
- Bacterial (more unwell, lethargic, temp (>38.5), refuse food)
are signs for subtle or obvious in kids compared to adults with pneumonia
kids more subtle clinical signs so CXR
signs of resp distress?
tachypnoea
- use of accessory muscles and rescission
- low oxy sats
Difficulty in breathing Hx: what RF are important?
- prematurity
- Neonatal care required
- Any cardiac or resp disease
Difficulty in breathing Hx: important things to ask about?
- Cough
- Feeding
- Fever
- Energy levels (drowsy/clingy vs running around)
- Snuffly nose
- Activity level
- Eating and drinking
- Ability to sleep
- How ill in past
difficulty in breathing: what do you look for on general examination
- Alertness, interest in surroundings
- Posture
- Ability to speak
in what conditions do you get wheezing?
- asthma
- bronchiolitis
- viral induced wheeze
In what conditions to you get stridor?
- Croup
- Foreign body aspiration
- Anaphylaxis
- Bacterial trachielitis
- Epiglotitis
in what conditions to you get grunting?
sign of significant resp distress (bronchiolitis)
Describe the trend of RR and resp distress
as resp distress develops => rate goes up to compensate (tachypnoea) => then rate slows
what should you also be looking for when calculating RR?
work of breathing
what 2 things indicate increased respiratory effort?
- recession of the ribs
- use of accessory muscles
what different types of recession (of the ribs) are there?
- Tracheal tug
- supraclavicular/sternal/intercostal/subcostal recession
in which age group is recision of the ribs more likely?
younger kids: soft chest wall => pulled in as breath in
why types of use of accessory muscles? signs?
- headbobbibg
- Abdominal breathig
- nasal flaring (babies)
in what condition might you get bronchial breathing?
pneumonia
how can you quickly know if child has emergency airway problem with choking?
if able o talk/cry then unlikely to be emergency airway problem
Choking: where is foreign body most often stuck?
stuck in oesophagus => encourage to cough
Choking: what happens if object stuck in larynx?
stuck in larynx => apnoeaic => unconscious or cardiac arrest
what would you see if there is inhaled from object in L or R main bronchus on CXR?
unilateral hyperinflated lung
what is Apnoea? how long?
Pause of stopping in breathing (>20 sec)
In what conditions might you get apnoea ?
- bronchiolitis
- whooping cough (pertussis)
- Sepsis
- meningitis
fits
what temperature fevers are considered concerning in <3 month old age group and >3 month old age group
<3 month: >38 degrees => concerning
>3 month: >39.5 degrees => concerning
what are common causes of fever?
- usually infectious cause (most commonly viral and self limiting but some serious bacterial infections)
- JIA
- Kawasaki
what is the point of the history + examination in a fever presentation?
- Differentiating minor from major infection
- Source of infection ! think top to toe
top to toe: what different infections could there be?
- Meningitis
- Otitis media
- Tonsilitis
- Croup
- Pneumonia
- Septic arthritis
- Osteomyelitis
- Surgical causes
- UTI
briefly describe sepsis
boys response to infection
inflammatory response => increased permeability of blood vessels + poor contraction of heart => loss of circulating fluids => shock and multiple organ failure
why does cap refill increased in sepsis?
peripheral shutdown (=> increase cap refill) => maintain vital organ perfusion
what do you need to ask about a fever Hx?
- The fever itself (temp_
- Colour: abnormally pale => red flag
- duration: >5 days is more concerning
- Eating and drinking
- Vaccination/immunisation Hx
- Perinatal Hx: preterm, cerebral palsy
how does fever control prevent febrile convulsions?
trick question. it doesn’t.
no evidence that tight fever control prevents febrile convulsions.
how does fever affect HR? by how much?
fever generally increases HR by 10 bpm
why is it useful giving an antipyretic (paracetamol/ibuprofen) to child with fever?
temp resolving => response to drug (not curing)
- allows you to recheck behaviour and physiology once temp brought down (re check HR + RR)
Why don’t rely on BP as a sign of shock?
Children have highly effective peripheral shutdown so BP maintained until v sick (decompensated shock)
how do you check for cause of fever on examination?
top to toe
- check for rash (all over)
- meningitis (bulging fontanel, neck stiffness, photophobia)
- Ottitis media: can often be misleadingly pink due to raised temp
- Chest auscultation
- Abdominal examination
- If nothing found so far: urine sample
baby <3 month old with signs of sepsis, what investigation should you consider?
consider CXR (babies have very subtle clinical signs for pneumonia)
complication of Kawasaki disease?
serious heart and CAD complications
Describe the symptoms for Kawasaki disease?
Fever (usually >39) for at least 5 days + 4/5 of following:
- maculo-papular rash
- conjunctivitis (bilateral, non-purulent)
- mucus membrane changes (strawberry tongue, red lips)
- unilateral cervical lymphadenopathy
- extremity changes: erthyma (palms, soles), swelling of fingers/toes
clinical signs of meningococcal septicaemia
(signs of circulatory problems)
- bulging fontanel
- Fever
- Rigors
- rash
- Increased RR + HR
- pale or mottled skin
- cold hands and feet
- sleepy/drowsy/difficult to wake
limbs/joints/muscle pain
- confused/delirious
- non blanching purpuric rash
what could cause a rash? (6)
- Infection
- Allergies
- Reaction to medications
- Stings and insect bites
- Chemical irritants
- Sign of systemic infection
usually: what does cough and sore eyes indicate?
measles
describe a vesticular rash? in what conditions might you see this (3) ?
little blisters
- Chicken pox, HSV, shingles
Describe petechiae
little pink or purple dots <2mm in size
describe urticaria? caused by?
inflamed looking, itching bumpy rash
- caused by allergy + anaphylaxis
child has a rash and a blistered mouth. what condition is this most likely to be and where else would you find blisters?
Stevens-Johnson syndrome
causes mouth and other mucus membranes to blister
Describe the rash seen in Kawasaki disease
non specific but usually macula papular
(widespread erythematous)
Describe the rash seen in hence schonlein Purpura and general appearance of the child?
immune disease causing bleeding into the skin (similar rash as meningococcal septicaemia but child is generally well
Complications of HSP?
bleeding also occurs in wall of intestine => abdo pain (+ possible intusscepeption)
- need to diagnose early as can cause kidney disease
- nephrotic syndrome
Child has widespread erythema + itching flushing. What is this most likely to be?
anaphylaxis - sever allergic reaction
describe signs you might find in anaphylaxis A-C?
Airway: lip/throat swelling, stridor
Breathing: bronchospasm
Circulation: peripheral vasodilation + hypotension
Diarrhoea
What is ITP and what kind of rash does it cause?
Idiopathic thrombocytopenia purpura: immune disease affecting platelets (=> clotting disorder)
- causes petechiae in skin (child completely well except rash)
ITP diagnosis and management
diagnosed with FBC + may need treatment with steroids
child presents with petechia or purpura. what do you need to consider ? what test do you need to do
Leukaemia
- will appear clinically anaemic
need to do FBC to not miss leukaemia or ITP
child presents with a rash mainly affected the legs and buttocks. What is this most likely going to be?
HSP
child presents with a rash mainly affected face and trunk. what is the most likely going to be?
chicken pox
causes of non-blanching rash? (3)
- meningococcal septicaemia
- HSP
- ITP
name some conditions that can cause fits (6)
- Encephalitits
- Head injury
- Poisoning
- Child abuse
- Febrile convulsions (most common)
- Breath holding attack
Key points to a fits history?
- Any warning signs
- LOC
- Appearance during fit
- Duration
- Duration of recovery
- Post even headache
Fits history: what to you want to know about the appearance during the fit?
- Eye movements
- Abnormal movements
- Colour
- Tone
- Incontinence
- Tongue biting
- Injuries
describe what a Hx would sound like for a non-epileptic event
child will describe tunnel vision, sound blurring, incontinence
- swift recovery <1 min
Describe when a febrile convulsion occurs and what it looks like
tonic clonic following viral infection
- Only lasts a minute and child makes full recovery (but can be a serious infectious cause - pneumonia, meningitis)
What might a fit in a baby look like? (3)
- jerking of limbs is less violent + more subtle
- Stare with eyes upwards
- Lip smacking
Why check blood glucose in a child who had a fit?
hypoglycaemia can cause fits in children
- If child unwell preceding fit (+ feeding poorly), type 1 diabetes, congenital metabolic disease + alcohol overdose
Why do you have do act quick when a child has been having a seizure for >5 mins
status epileptics: if >30 min => brain damage + death
generally what 2 ways cause dehydration?
- Lost a lot of fluid
- Not taking in enough fluid
What is the most common cause of dehydration
gastroenteritis (rotavirus)
What other symptoms are important in a dehydration Hx?
- diccifuly in breathy
- fever
- Rash
- Sore throat
- Urinary symptoms
Dehydrated child with blood in stool. Most likely cause?
salmonella/shigella/campylobacter but could be intuessesception
what 2 things could jitteriness in babies indicate?
- dehydration
- hypoglycaemic
Signs of dehydration?
- Sunken eyes (ask parent), sunken fontanelle
- dry mucus membranes (lips, tongue, eyes - sunken + tearless)
- peripheral temp, mottled kin (due to peripheral vasoconstriction)
- Skin turgor
- Capillary refil time
in which age group is pyloric stenosis most common?
4-6 week age group
what causes pyloric stenosis? how does it cause dehydration?
muscular swelling at outlet of stomach wchih stops food going into the duodenum => distension => vomiting at end or after feed
forceful projectile vomiting => severe dehydration
Explain physiology of hypernatraemic dehydration?
babys have immature kidneys => kidney unable to compensate dehydration => imbalance of Na + water => increase blood sodium
What should you always consider in a child with moderate-severe dehydration (and increased RR)
DKA
(increased RR driven by acidosis)
what could the causes of abdominal pain be? (4)
- problem in abdo
- Infection elsewhere (throat)
- migraine
- Stress (school or home)
name some abdominal causes of abdominal pain (7)
- Colic
- Intussusception
- Meseenteric adenitis
- Appendicitis
- Constipation
- IBD
- Coeliac disease
Name some extra-abdominal causes of abdominal pain (4)
- Migraine
- DKA
- Infection elsewhere (pneumonia, UTI)
- Stress
what are the important things you are trying to differentiate in an abdominal pain history? (3)
- Acute vs chronic
- Medical vs surgical
- Something serious
name some surgical causes of abdominal pain
- Intussusception
- BO
- Appendicitis
- Meckels diverticulum
Patient presents with billows vomit, what must you consider
bowel obstruction
Patient presents with abdominal guarding, fever, increased HR, increased RR. what should you consider? what most commonly causes this?
patient is guarding + signs of sepsis
- peritonitis most commonly caused by a perforated appendix
Child presents with tonsillitis and sever abdominal pain. what should you consider? explain
intussusception (invagination of intestine on itself => BO - life threatening)
- associated with otnsilits + ear infections (make lymph nodes in bowel swell)
(Related to HSP)
what is the name of the lymph nodes in bowel
Peyers patches
what do you have to consider in boys that present with abdominal pain?
testicular torsion
name some symptoms of cerebral oedema (4)
- Drowsy
- Out of character
- Persistent headache
- Persistent vomiting
child present with a head injury. parent says that they vomited. after how many times vomiting should you be concerned? then what would you do?
once/twice is quite common
- More => CT scan
What questions would you ask for a head injury history?
- Falls Hx: high high, LOC (how long for)
- behaviour since injury
- Persistent headache
- Vomiting since injury
- Is the Hx consistent (NAI)
