Paediatrics: basic life support and Fluids Flashcards
Paediatric basic life support: basic points from algorithm
- unresponsive?
- shout for help
- open airway
- look, listen, feel for breathing
- give 5 rescue breaths
- check for signs of circulation: infants use brachial or femoral pulse, children use femoral pulse
Resuscitation: children
- 15 chest compressions: 2 rescue breaths
- chest compressions should be 100-120/min for both infants and children
- depth: depress the lower half of the sternum by at least one-third of the anterior–posterior dimension of the chest (which is approximately 4 cm for an infant and 5 cm for a child)
- in children: compress the lower half of the sternum
- in infants: use a two-thumb encircling technique for chest compression
New-borne rescuscitation
- Dry baby and maintain temperature
- Assess tone, respiratory rate, heart rate
- If gasping or not breathing give 5 inflation breaths= different from ventilation breaths, the aim is to sustain pressure to open the lungs
- Reassess (chest movements)
- If the heart rate is not improving and <60bpm start compressions and ventilation breaths at a rate of 3:1
Formula to calculate weight
(2 x age in years) + 8 in kg
Paediatric sepsis 6
- Give high flow oxygen
- Obtain IV access and take blood tests: cultures, glucose and blood gas (+lactate)
- Give IV antibiotics
- Consider fluid rescusitation
- Involve senior support early
- Consider ionotropic support early
Surgical emergencies: Mesenteric adenitis
- Vague central abdominal pain (sometimes moves)
- No signs of peritonism, may have cervical lymphadenopathy
- Mildly raised inflammatory markers (lymphocytes predominate)
- May be accompanied by viral symptoms like myalgia/headache or sore throat
Surgical emergencies: Meckel diverticulitis
- History similar to appendicitis
- Tenderness medial to McBurney’s point
- Raised inflammatory markers
- Can cause intussusception or volvulus
- Signs of peritonism may be present
Birthweight
- Average birthweight in Europe = 3.5kg
- Low birthweight = < 2.5kg
- Very low birthweight = <1.5kg
- Extremely low birthweight = <1kg
Fluid treatment ladder
- Shock (>10%)= fluid bolus 20ml/kg 0.9% saline stat
- A shocked child who is now stable/ red flags and deteriorating/ Persistently vomiting ORS via PO/NG route= IV maintenance fluids + deficit
- Clinical dehydration (5-10%)= PO maintenance fluid + deficit, give oral rehydration salts, consider BGT if vomiting
- Gastroenteritis (no signs of dehydration)= encourage usual PO intake +/- oral rehydration salts if dehydrated
Surgery: fasting
- 6 hours before surgery no solids
- 2 hours before surgery no clear liquids
Children on IV fluids need daily U&E’s
Holliday- Segar formula
How we work out maintenance fluids:
* First 10kg weight – 100ml/kg/24 hours
* Second 10kg weight – 50ml/kg/24 hours
* Any kg > 20kg weight – 20ml/kg/24 hours
* Maintenance fluid of choice – 5% dextrose with 0.9% sodium chloride (+/- potassium)
* Potassium requirement 1-2mmol/kg/24 hours
Vaccines for babies under 1 year old
- 8 weeks= 6 in 1 vaccine, Rotavirus, MenB
- 12 weeks= 6 in 1 vaccine (2nd dose), Pneumococcal (PCV), Rotavirus (2nd dose)
- 16 weeks= 6 in 1 (3rd dose), MenB (2nd dose)
Immunisation: children aged 1 to 15
- 1 year= Hib/MenC (1st dose), MMR (1st dose), Pneumococcal (PCV)-2nd dose, MenB (3rd dose)
- 2 to 10 years= Flu vaccine (every year)
- 3 years and 4 months= MMR (2nd dose), 4 in 1 pre-school booster
- 12 to 13= HPV vaccine, 2 doses 6 to 24 months apart
- 14 years= 3 in 1 teenage booster, MenACWY
Immunisation: adults
- 50 years and every year after= flu vaccine
- 65 years= Pneumococcal (PCV) vaccine
- 70 years= shingles vaccine
- Pregnant women= flu vaccine and Whooping cough (pertussis) vaccine
6 in 1 and 4 in 1 preschool booster
6 in 1 vaccine= Diphtheria, tetanus, pertussis (whooping cough), polio, Haemophilus influenzae type b (Hib) and hepatitis B
4 in 1 pre-school booster= Diphtheria, Tetanus, Pertussis and Polio
Determinants of childhood growth
- Fetal (30% of adult height): uterine environment
- Infants (15% of adult hight): Nutrition, good health and happiness, thyroid hormones
- Childhood (40% of adult height): Genetics, Good health and happiness, Growth hormones, Thyroid hormones
- Pubertal (15% of adult height): testosterone and oestrogen, growth hormone
Growth charts
Height and weight (+/- head circumference) should be plotted at every clinical encounter. Important tool to compare growth of an individual to the normal population.
Faltering growth
- Pattern of slower weight gain than expected for age and sex in children, often falls across weight centiles
- Mechanisms= inadequate output, poor absorption, excessive demand, excessive output
Investigations for faltering growth in infants
- Bedside= observe feeding (infant), urine dip and culture, ECG, blood glucose
- Bloods= FBC, inflammatory markers, U&E, LFT, bone profile, TFT, blood gas
- Imaging= ECHO
- Special tests= Sweat test, Endoscopy, Home visit +/- admission
normal head growth
- Most head growth occurs in the first 2 years of life
- Anterior fontanelle close by 12-18 months
- Posterior fontanelles close by 8 weeks
Microcephaly
- Head circumference below the 2nd centile
- Familial – present from birth and proportional, normal development
- Genetic – associated with developmental delay
- Congenital infection
- Acquired insult to the developing brain – accompanied by CP and seizures
Macrocephaly
- > 98th centile
- If increasing rapidly (in an infant)- must exclude raised intracranial pressure
- Causes: tall stature, familial, endocrine or CNS storage disorder
SUDI and risk factors
Sudden, unexpected death of an infant under 1 year of age. Death that remains unexplained after post mortem examination and case review are classified as Sudden Infant Death Syndrome (SIDS). 80% of cases.
Risk factors= Maternal smoking, Preterm birth, Late or no antenatal care, IUGR, Placental abnormalities, Sleeping position, Bed sharing, Bedding
Newborn blood spot test
- Done on day 5 of life
- Screens for 9 conditions= SCA, CF, Congenital Hypothyroidism, PKU, MCADD, Maple syrup urine disease, Isovaleric Acidaemia, Glutaric Aciduria Type 1, Homocystinuria
Paediatric fluid prescribing
Why might a child need fluids= Sepsis, Bleeding, NBM, Increased losses and Dehydration
Children have a higher fluid requirement/kg than adults- higher SA:Vol ratio and higher basal metabolic rate
Oral rehydration in gastroenteritis
- Age under 5: 50ml/kg of ORS over 4 hours (~2ml/kg every 10 minutes) in addition to maintenance volume
- Age over 5: 200ml of ORS after each diarrhoeal episode (in addition to normal fluids)
Fluids to give in resuscitation
- If children and young people need IV fluid resuscitation, use glucose‑free crystalloids that contain sodium in the range 131–154 mmol/litre, with a bolus of 20 ml/kg over less than 10 minutes.
- Take into account pre‑existing conditions (for example, cardiac disease or kidney disease), as smaller fluid volumes may be needed.
- Neonates different.
Choice of fluids
- For a child (>28 days of age), first line maintenance fluid is usually isotonic crystalloids + 5% glucose (e.g. 0.9% sodium chloride + 5% glucose).
- In shock start with 0.9% saline
- For a term neonate (<28 days of age) with no critical illness: 10% dextrose +/- additives
Over a 24 hour period, males rarely need more than 2500ml and females rarely need more than 2000ml of fluids
Potassium
- Add in to maintenance fluids for patients who are not eating/patients on insulin/patients with low potassium
- Aim for 1-3 mmol/kg over 24 hours
- Usually given in alternate bags in paeds
- Can be added to fluid as either 10 or 20 mmol
Assessing dehydration/shock
Oral fluid challenge 2ml/kg every 10 minutes with ORS in clinically dehydrated but not shocked children. Reassess at 2h. If a child has impaired BP and perfusion they will receive a bolus (10-20ml/kg).
Clinical dehydration vs clinical shock
Clinical dehydration= appears to be unwell or dehydrating, reduced skin turgor, dry mucous membranes, sunken eyes, reduced responsiveness i.e. irritable, lethargic and decreased urine output
Clinical shock= Decreased levels of consciousness, Pale or mottled skin, Cold extremities, Tachycardia, Tachypnoea, Weak peripheral pulses, Prolonged cap refill and Hypotension.
Replacing fluid deficit
- For dehydrated children who need IV fluids (e.g. they received a bolus, or cannot maintain adequate hydration enterally)
- 100 ml/kg for children who were initially shocked (10% deficit) over 48h
- 50 ml/kg for children who were not initially shocked but were dehydrated (5% deficit) over 48h
- E.g. If a 10kg child requires a bolus initially, they will get an extra 100ml x 10kg rehydration = 1000ml/48h
- You will need to do maintenance fluid on top of
Prescribing fluid for losses
- Losses are given back over 4 hours i.e. if 40ml lost via NG, 10ml/hr given over 4 hours in addition to maintenance/dehydration IVT.
- Given through 0.9% sodium chloride with 10mmol KCL
DKA categories fluid
- pH < 7.3 and/or Bicarb <15 MILD DKA - Assume 5% deficit
- pH < 7.2 and/or Bicarb <10 MODERATE DKA - Assume 5% deficit
- pH < 7.1 and/or Bicarb <5 = SEVERE DKA Assume 10% deficit
DKA with shock at presentation
Needs a 10ml/kg bolus STAT and escalation for senior support. This bolus is not subtracted from overall deficit. All children without shock who need IV fluids now given an initial 10ml/kg bolus over 30 minutes. This is subtracted from overall deficit.
Some medications avoided in children
- Aspirin- risk of Reyes syndrome, not used in under 16s unless for specific illnesses such as Kawasaki’s
- Tetracyclines- discolouration of developing teeth. Not given in under 12s
- Nitrofurantoin- risk of haemolytic anaemia in under 3 months
- Ceftriaxone- risk of biliary stasis in under 1 month
Differences in how adults and children absorb medication
- Size
- Varying developmental stages
- Body water/fat proportions
- Differing metabolic rates at different ages
- Adversion to medicines
- Children not generally used in clinical trials for drug safety
Prescribing in children
- More dose calculations required
- More consideration to formulation required – Use of suspensions which may come in differing strengths.
- Wide range of dosages which vary by indication/route
- Much more off license use of drugs
Patterns of bruising suggestive of physical child abuse
- Bruising in children who are not independently mobile
- Bruising in babies
- Bruises seen away from bony prominences
- Bruises to the face, back, abdomen, arms, buttocks, ears and hands
- Multiple bruises in clusters
- Multiple bruises of uniform shape
- Bruises that carry the imprint of an instrument or ligature
Thermal injuries and sex abuse
Thermal injuries= either intentional, neglectful or Accidental. Abusive burns are seen in 10% of patients admitted. Often get glove and stocking scalds in abuse.
Sex abuse= use a Sexual exploitation risk questionnaire to screen for it
When should you disclose information against consent
If a child or young person does not agree to disclosure there are still circumstances in which you should disclose information:
*when there is an overriding public interest in the disclosure
* when you judge that the disclosure is in the best interests of a child or young person who does not have the maturity or understanding to make a decision about disclosure
* when disclosure is required by law.
Domestic abuse in the house
- Give victim local information on domestic violence help and escape planning
- Complete a cause for concern form
- Refer to children’s services (mandatory if victim or perpetrator is under 18 or have dependents under 18)
- Assess the risk (DASH)- consider MARAC (Multiagency risk assessment conference) referral
- Contact social services or the police if its an emergency
Talking to parents and dealing with child disclosure
Talking to parents= it is good practise to inform and involve the parents at every step of the safeguarding process except where it will lead to an unacceptable risk for the child.
If a child discloses to you- do not promise confidentiality, document the discussion, discuss with senior
Components of the healthy child programme: Antenatal screening
- Fetal Anomaly Screening Programme (FASP)
- Screening for Down’s
- Screening for sickle cell, thalassaemia
- Screening for infectious diseases (rubella, syphilis, hep B, HIV)
Components of the healthy child programme: after birth
Newborn screening
- The Newborn and infant physical examination (NIPE) (by 72h)
- Newborn Hearing Screening Programme (NHSP)
- Newborn hearing screening test
- Newborn blood spot (heel prick)
INFANTS
- The new baby review (at around 14 days old)
- The baby’s 6 to 8-week examination
It is also recommended in the Healthy Child Programme that by the age of five, and soon after school entry, each child should have their vision and hearing assessed.
Barlow vs Ortolani tests
Barlow’s test – IDs hips which are dislocatable
Ortolani’s test – IDs hips which are dislocated and is used to confirm diagnosis
Developmental red flags
Infants - no social smile by 6-8w
Toddlers - not walking or talking by 18m; not linking words by 2y
Preschoolers - no collaborative play; language not discernable by non-family
Regressions at any age
Common causes of regression
1) Duchenne muscular dystrophy (boys only), other dystrophies
2) Spinal muscular atrophy
3) Progressive and untreatable blindness
Vitamin recommendations for kids
Recommended to supplement breast milk with vitamin D (formula has vit D added).
All kids 6 months – 5 years should take vitamins A, C, and D.
When do teeth come in
6-30 months for baby teeth
6-13 years for most adult teeth
17 years on for wisdom teeth
Knocked out tooth management
NEVER put a baby tooth back in place
Wash a dirty tooth for max 10s under cold running water and reposition in mouth
- tetanus booster if nec.
- consider abx
If not possible, place tooth in milk or saline
Seek immediate dental treatment
Fluoride varnish
can be applied 2x a year for kids over 3 (by a dental professional)
and more often in kids 0-6y giving concern
