Paediatrics: Emergency Med Flashcards
What is overall approach to seriously unwell child? (3)
- Primary ABCDE assessment and resuscitation
- Secondary assessment + emergency treatment
- Stabilise and transfer
What is aim of ABCDE assessment? how long?
to identify life threatening problems to guide resuscitation
- should take less than a min
ABCDE: A?
airway assessent
- look, listen + feel for airway latency (head tilt)
ABCDE: B what 3 things do you assess for?
Breathing assessment
- effort (how much work going into breathing)
- Efficacy (what are they achieving in terms of air movement + gas exchange)
- Effect (of resp inadequacy of rest of body)
Signs of resp distress
- Increased RR
- sob
- grunting
- flaring nostrils
- tracheal tug
- use of accessory muscles
- gasping (late sign of sever hypoxia)
When might child not show signs of increased resp effort?
- when severe resp problem for some time (=> fatigued)
- neuromuscular disease
- central resp depression
what could cause central resp depression (3)
- raised ICP
- hypoventilation
- opiates
How does hypoxia affect HR?
tachycardia (when prolonged => Brady)
ABCDE: what do you look for in C? (4)
circulation assessment
- HR, pulse vol, cap refill, BP
name some effects of circulatory inadequacy
affects other organs
- increased RR (driven by metabolic acidosis (lactic acid))
- decreased urine output
- mottled skin with pale/cool peripheries
ABCDE: what do you do for D?
Disability )neurological) assessment
- AVPU or GCS
What does AVPU start for?
- Alert
- Voice (responds to)
- Pain (responds to)
- Unresponsive
what GCS score would a patient have if they only responded to pain on AVPU scale?
GCS 8
ABCDE: what is E? what do you look out for?
Exposure
- swift head tot toe examination to look for clues of underlying pathology
- Fever, rash, bruising
Resp rate trend in kids? when does it reach adult level? what?
RR decreases with age
- by 12 it is like adult (12-20)
Resp: child found to have bubbling sound. what is diagnosis? emergency treatment?
excessive secretions
- suctioning
Resp: child found to have harsh stridor and a barking cough. what is diagnosis? emergency treatment?
Croup
- oral dexamethosone (and adrenaline in severe cases)
Resp: child found to have soft stridor, drooling and a fever in a sick looking child. what is diagnosis? emergency treatment?
Bacterial tracheitis or epiglottitis
- intubation by anaesthetist followed by IV Abx
Resp: child found to have sudden onset stridor with Hx of inhalation. what is diagnosis? emergency treatment?
inhaled foreign body
- Laryngoscopy for removal
Resp: child found to have stridor following ingestions or injection of a known allergen. what is diagnosis? emergency treatment?
anaphylaxis
- IM adrenaline
Resp: child found to have wheeze. what is diagnosis? emergency treatment?
Acute asthma
- Bronchodilators
Resp: child found to have bronchial breathing. what is diagnosis? emergency treatment?
pneumonia
- IV Abx
what is (paediatric) shock?
life threatening condition caused by systemic failure of circulatory system => inadequate perfusion => ischaemia => multi-organ failure
(failure of circulatory system to adequately perfuse major organs)
Do kids show medical signs earlier or later than adults. why?
show fewer signs (die to high physiological reserves)
how to calculate CO
CO = HR x SV
(cardiac output = heart rate x stroke vol)
how to calculate MAP?
MAP = CO x TPR
(mean arterial pressure = cardiac output x total peripheral resistance)
what things could fail (generally) that lead to shock (3)
failure of circulatory system
1) heart
2) blood vol
3) blood vessels
What 4 different types of shock are there? describe them
- Hypovolaemic
- Obstructive
- Cardiogenic
- Distributive
what is compensated shock? some signs?
neural and hormonal mechanisms to maintain BP (=> and perfuse vital organs)
- Tachycardia (=> increase CO)
- redistribution of blood (away from peripheries to vital organs), increased cap refill
- tachypnea (reduce anaerobic resp)
- reduce urine output
what uncompensated shock? when does it develop to this?
mechanisms not enough to maintain BP => insufficient vital organ perfusion => uncompensated shock (=> bad prognosis)
what is distributive shock? pathophysiology?
Redistribution of NORMAL blood vol
- systemic vasodilation (all vessels) => shift of blood in vasc system => reduced blood flow to major organs (heart, brain, kidney)
What is hypovolaemic shock? pathophysiology?
reduced circulating blood vol => reduced CO => decreased perfusion
What is cardiogenic shock? pathophysiology?
heart itself fails => reduced CO => reduced perfusion
What is obstructive shock? pathophysiology?
obstruction to outflow of blood from heart
What kind of shock does sepsis cause?
Distributive and/or hypovolaemic
how does sepsis cause shock?
- infection => inflam cytokine release => NO release => systemic vasodilation
- cytokine release => endothelial lining more permeable => fluid leak to ICS => oedema => reduced circulating vol
What kind of shock does dehydration cause? other examples of this type?
hypovolaemic
- dehydration
- third spacing
- bleeding
- sepsis
what could cause cardiogenic shock? (4)
- myocarditis
- cardiomyopathy
- arrhytymias
- congenital heart disease
what could cause obstructive shock? (4)
- tamponade
- PE
- tension pneumothorax
- coarctation of the aorta
clinical features of uncompensated shock
- uncompensated: altered mental state, hypotension, low oxy sats, weak/thready pulse, cold grey mottled skin, low body temp
Clinical features of irreversible shock? what lead to?
- irregular slow pulse, unconscious
- unmeasurable BP
- lead to cardiac arrest
Paediatric shock management ?
- A-E assessment
- Commonly as result of dehydration or fluid shifts so: IV fluid resuscitation
- if not responding: vasoconstrictive agents (IV adrenaline)
treat underlying pathology
complications of paediatric shock
secondary to ischaemia
- CNS failure
- DIC
- Resp failure
- AKI
- GI ischaemia
- Death
What is sepsis?
Dysregulated systemic inflam response to infection causing organ damage (=> death)
most common feature of sepsis (symptom) in kids?
fever or Hx of fever
non-blanching rash suggests infection from which organism?
N. meningitides
(Neisseria meningitidis)
Explain sepsis pathophysiology (3 kinda things)
pro-inflam cascade
- vasodilation
- decrease circulating vol
- (DIC) fibrin deposits, haemorrhage, inability to clot
Describe immune response in sepsis
pro-inflam cascade
- pathogen recognised => macrophages + lymphocytes + mast cells release cytokines (to alert immune system) => NO release => vasodilation
- cytokines make endothelial lining increase permeability => fluid leak to ICS => oedema => decrease circulating vol
-coagulation activation => fibrin deposit in circulation => thrombocytopenia => haemorrhage + inability to form clots (DIC)
Paed sepsis RF. Hx of what? (6)
- neonates + babes < 3 months
- premature
- prolonged ROM
- lateral colonisation with group B strep
- immunocompromised children
- Hx of fever, lethargy, vomiting, headache
paeds sepsis. what found on examination
- can be v non-specific
- signs of shock
- fever/hypothermia
- poor feeding
- inconsolable high pitched cry
sepsis blood gas acidity? why?
metabolic acidosis
- blood lactate risk due to anaerobic resp in hypo perfused tissues
Sepsis management (what difference form adult management)
sepsis 6
- take blood cultures
- check blood lactate
- monitor urine output
- give high flow oxy
- IV/IO fluid
- IV/IO Abx
- children prone to hypoglycaemia so currently with 2ml/kg 10% dextrose bolus