Paediatrics Emergencies

Question 1

What clinical features might be associated with anaphylaxis in a child?

Answer 1

Initial symptoms:
• Pruritis (itchy skin), erythema (redness), urticarial (hives red raised rash)
• Rhinitis (runny nose), conjunctivitis, angio-oedema

General symptoms:
• Palpitations (noticeable heart beat) and tachycardia
• Nausea & Vomitting, abdominal pain
• Collapse and LOC

Airway symptoms:
• Itching of palate of external auditory meatus
• Dyspnoea
• Bronchospasm (wheezing) → oedema & acute stridor
• Cyanosis
• Circulatory collapse (rare) – reduced CRT, hypotension, tachy

Question 2

What is the initial management algorithm for a child with anaphylaxis?

Answer 2

Lay patient flat and carefully raise legs.

A: Obstruction, swelling? Signs of allergen? Call for help → intubation. High flow O2 (15L; non-rebreathe)

B: Auscultate. Signs of respiratory distress: tracheal tug, nasal flaring, intercostal recession, head bobbing.

C: Colour, oulse, BP, cap refill. IV fluid challenge (20mL/kg of 0.9% NaCl over 5 mins). Maintenance fluids (100ml/kg for 1st 10kg, 50ml/kg for next 10kg, 20ml/kg after that).

D: Conscious level? Blood glucose? Pupillary response?

E: System review.

Drugs:
- Adrenaline (IM injection): 
12+ 500mcg; 
6-12yo 300mcg; 
<6yo 150mcg

Repeat after 5 minutes if no effect.

• Chlorphenamine: antihistamine after resus.
  12+ 10mg;
  6-12yo 5mg;
  <6yo 2.5mg.
• Corticosteroids: IV hydrocortisone.
  12+ 200mg;
  6-12yo 100mg;
  <6yo 50mg.
• Salbutamol (inh), ipratropium bromide (inh); aminophylline (IV). Relieve bronchospasm.

Question 3

How much adrenaline would you administer for an 8yo child in anaphylaxis?

Answer 3

300mcg

Repeat every 5 minutes if no effect.

• Adrenaline (IM injection):
  12+ 500mcg;
  6-12yo 300mcg;
  <6yo 150mcg

Question 4

What blood pressure should you aim for when deciding whether to give a fluid challenge to a child in anaphylaxis?

Answer 4

0-1 month → 50-60 mm Hg

< 1 year → >70 mm Hg.

> 1-10 years → 70 + (age in years x2) mm Hg.

> 10 years → minimum 90 mm Hg.

Repeat challenge if no improvement, unless signs of fluid overload.

Question 5

What dose of fluids would you administer for a child in shock?

Answer 5

Fluid challenge: 20mL/kg of 0.9% NaCl over 5 minutes.

Maintenance: 100ml/kg/day for 1st 10kg, 50ml/kg/day for next 10kg, 20ml/kg/day after that.

Question 6

Which serological marker should you measure to confirm a diagnosis of anaphylaxis? When should samples be collected?

Answer 6

Serum mast cell tryptase

Collect a sample at the time anaphylaxis is suspected and another sample at follow-up to compare.

Question 7

What is the paediatric life support algorithm for a child showing no signs of life?

Answer 7

UNRESPONSIVE?
↓
Shout for help (if alone, proceed with 1 min of CPR before leaving to get help)
↓
Open airway
↓
NOT BREATHING NORMALLY?
↓
5 rescue breaths
↓
NO SIGNS OF LIFE?
↓
15 chest compressions
↓
2 rescue breaths
15 chest compressions

Always do 1 minute of CPR first if alone, then go for help.

Question 8

How would you assess a collapsed child?

Answer 8

ABCDE assessment algorithm

A:

• Assess patency (look, listen, feel)
• Vocalisations (crying or talking) suggest degree of patency; silence may indicate total obstruction.
• Paradoxical chest and abdominal movements
• Visible obstruction?
• Cyanosis/hypoxia

B:

• Respiratory rate
• Recessions
• Accessory muscles
• Flaring of nostrils
• Additional noises: wheeze, stridor, crepitations
• Grunting
• Posture/position
• Auscultate: equal entry?
• Percuss
• Tracheal deviation
• Gasping
• O2 sats
• Chest movement

C:

• Vitals: HR, pulse volume, BP
• Perfusion: cap refill, temp, colour
• Urine output

D:

• Consciousness (AVPU)
• Pupils
• Posture
• Blood glucose
• Evidence of seizure?

E:

• Expose the patient (maintain dignity and minimise heat loss) to assess for injuries, infections, bleeding etc.
• Core temp and physiological markers
• Full history and examination
• Review drug and fluid charts
• Investigation results
• Reassess A-E

Question 9

How might you respond to your assessment of a collapsed child?

Answer 9

A:

• Call for help if signs of airway obstructions
• Basic airway manoeuvres (neutral; head tilt; chin lift, jaw thrust)
• Airway adjuncts (OP, nasopharyngeal)
• Suction secretions
• Give O2
• Call on-call anaesthetist

B:

• Manual ventilation with bag and mask
• O2 15L/min via reservoir bag
• Aim O2 sats 94-98%
• Blood gas (venous or capillary in small children)
• Chest XR

C:

• IV access (or IO if required)
• Take blood for gas, glucose stick test, and lab tests
• 12-lead ECG
• Fluid bolus challenge (20ml/kg)

D:

• Protect airway
• Endotracheal tube (ET) intubation if GCS 8 or lower (call for anaesthetic help)
• Recovery position if airway not protected
• Give glucose if hypo (<4 mmol/L)
• Benzodiazepines for seizures

E:

• Seek senior advice
• Management plan
• Documentation
• Communication (SBARR)
• Transfer to HDU/ICU if appropriate

Question 10

What is the management algorithm for a choking child?

Answer 10

If coughing effectively, encourage to continue. Otherwise:

1. Call for help
2. Administer 5 back blows between shoulder blades (hold infants with free arms, place small children over your lap)
3. If unsuccessful, turn infant supine or stand child up and deliver 5 chest or abdominal thrusts.