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
What is epilepsy (definition)?
umbrella term for tendency to have seizures (spontaneous abnormal electrical brain activity)
What is aura?
sensory disturbance that precedes an attack
Epilepsy RF? (4)
- genetic (30% of patients have first degree rel)
- developmental abnormalities
- trauma/surgery
- hypoxia
Describe pathophysioly of epilepsy
abnormal synchronised discharge of neurones
- normal inhibitory mechanism fail + lowered seizure threshold => hyper-excitable neurones
Common epileptic triggers? (5)
- sleep deprivation
- Physical/mental exhaustion
- Alcohol/Drug misuse
- flicker lights
- Infection (meningitis common in 3rd world)
name the two overall types of siezures, where do they affect?
- Focal (single area of brain)
- Generalised (bilateral)
Describe generalised tonic clonic seizure. chronology, time course
(sometimes: preceded by aura)
- LOC + tonic phase (muscle tensing 10-60 secs)
- Followed by clonic phase (muscle jerking seconds-minutes)
- post ictal period
tonic clonic seizure associated symptoms (4)
- Tongue biting
- Incontinence
- Groaning
- Prolonged post octal period (patient confused, drowsy, irritable, low)
medical Management of generalised tonic clonic seizures (ongoing)
- sodium valproate (first line)
- Lamotrigine/levetiracetam or carbamazepine (2nd line)
where do focal siezures start and what do they affect?
start in temporal lobes
- affect hearing, speech + memory
What might focal seizures involve? (presentation)
- hallucination
- memory flashbacks
- deja vu
- doing strange things on autopilot
Management of focal seizures (medical)?
- Lamotrigine or carbamazepine (1st line)
- sodium valproate (2nd line)
(reverse of tonic clonic)
Describe absence seizures, type? after attack? duration?
(generalised)
- blank, unresponsive to stimuli but conscious
- after attack: normal function resumes
- listless than 15 secs
describe atonic seizure, type? Management ? first/second line?
generalised (brief lapse in muscle tone)
first line: ethosuximide
second line: sodium valproate (male), lamotrigine or levetiracetam (female)
carbamazepine may exacerbate absence seizures
describe myoclonic seizure, type?
generalised
- sudden brief muscle contractions
(can be focal too. in focal epilepsy, the muscle jerks affect only one side of the body)
Epilepsy investigations? diagnosis?
- good Hx
- EEG
Diagnosis: 2 unproved seizures occurring more than 24 hrs apart
epilepsy overall management
monotherapy
- sodium valproate (1st line except for focal)
What is status epilipticus?
Medical emergency
- seizure lasting more than 5 mins (or 2 or more seizures without regaining consciousness)
status epilipticus management?
medical emergency
- ABCDE
What is a febrile seizure? (not caused by?)
type of seizure that occurs in children with high fever not caused by epilepsy of underlying neuropathology (not CNS infection)
During what ages do febrile seizures occur?
6 months - 5 yrs
What is the most common paediatric neurological condition?
febrile convulsions/siezures
Febrile seizure patholophysiology?
reaction of developing brain to fever + genetic predisposition/environmental factors => increased excitability => more prone to seizure
Febrile seizure aetiology ?
- viral infections are associated with triggering 80% fo febrile convulsion cases
- Upper or lower resp tract infection, Otitis media, UTI
Febrile seizure RF?
- FHx (predisposes to febrile convulsions)
- Seasonal (higher provenance of viral infection in winter)
describe simple vs complex febrile convulsions. what? time? how often?
Simple: generalised tonic clonic seizure < 15min, only once
Complex: partial of focal seizure or last>15min, or occur multiple time in febrile illness
clinical features of febrile seizure? age ? fever what temp ?
- fever> 38degrees
- age (6 months - 6 yrs)
- tonic-clonic seizure
- Symptoms suggestive of infection (cough, ear ache, diarrhoea, dysuria)
Febrile convulsion investigations + diagnosis?
diagnosis: other neuro pathology must be excluded
Investigations: general obs 9confirm fever + monitor for signs of sepsis)
Febrile seizure differential (6)
- Epilepsy
- Meningitis/enchepalitis
- Intracranial space occupying lesion (brain tumour, intracranial haemorrhage)
- Electrolyte abnormality
- Trauma (non-accidental?)
- Delirium
Febril convulsion management
(if first episode then go to hospital)
- Acute management: ABCDE, cushion head + remove hazards, paracetamol/ibuprofen (to reduce temp), explain diagnosis to parents
- If Seizure lasts >5min (status epilepticus): emergency benzodiazepines (lorazepam)(as unlikely to resolve by itself)
- If complex seizure of administered meds: admit to hospital
briefly describe physiology of T1DM, describe the insulin and glucose levels
disease where pancreas tops producing insulin
- No insulin => body think its is in fasting state (with low glucose) => hyperglycaemia
what is insulin? where produced? anabolic or catabolic?
Anabolic hormone produced by beta cells in islets of langerhans (in pancreas)
what effect does insulin have on blood sugar? in what 2 ways does it do this?
decreases blood sugar
- causes muscle + liver cells to absorb glucose from blood + store as glycogen (without insulin, cells cannot take up + use glucose)
- supresses glucagon, decrease glycogenolysis, decrease gluconeogenesis
what type of hormone is glucagon and where is is produced? anabolic or catabolic?
catabolic hormone produced by alpha cells in islet of langerhans
how does glucagon effect blood sugar levels and how is this done
increase blood sugar
- breakdown liver glycogen store (glycogenolysis)
- invert protein + fat into glucose (gluconeogensis)
What is ketogenesis? when does it happen? what is the energy source?
insufficient supply of glucose + glycogen stores exhausted => liver converts fatty acid to ketones (water soluble FA that can cross BBB)
What is the hyperglycaemia symptom
triad?
- Polyuria
- Polydypsia
- Weight loss
what does the long term management of to T1DM involve?
- Patient + fam education (life long disease)
- SubCut insulin regime
- Monitoring dietary carb intake
- Monitor blood sugar, monitor + manage short + long term complications
describe the insulin regime for T1DM
- Basal (long acting insulin - constant background insulin trough day)
plus - Bolus (short actin insulin 30 min before carb intake)
why do you need to avoid injecting insulin at the same site?
can lead to lipodystrophy (SC fat hardens)
what can cause hypoglycaemia in a T1DM patient? what would be the symptoms
caused by: increased insulin, low carbs or not processing carbs properly
- Symptoms: hunger, tremor, sweating, irritability, dizziness, pallor
What are the long term complications of choleric hyperglycaemia?
- Macrovascular: CAD, Peripheral ischaemia (diabetic foot), stroke, HTN
- Microvascular: peripheral neurophay, retinopathy, KD
- Infection: UTI, pneumonia, oral/vaginal candidiasis
What is a BRUE? describe it? what age group?
Brief resolved unexplained event
- event occurring in an infant < 1 year
- Sudden, brief, and now resolved episode of cyanosis, decreased or irregular breathing, marked change in tone, altered level or responsiveness
what are the 4 counter regulatory hormones that rise in DKA?
- Glucagon
- Cortisol
- Catecholamine
- Growth Hormone
A child comes to see you with Beverly sore throat and limited neck movement. No neurological signs or reduced consiocuness, uvula is central, no stridor or drooling. considering clinical features what diagnosis would you ant to rule out?
Retropharyngeal access (can be life threatening if not diagnosed early)
what is the means duration of symptoms before a child presents with DKA?
16.5 days
what is the typical age range for febrile seizures?
6 months - 5 years
what age group is the peak frequency for choking episodes?
1-2 years
choking child: over what age should abdominal thrust be used?
in a child over 1 abdominal thrusts should be used
(encourage coughing => 5 back blows => 5 abdominal thrusts)
which of these signs suggest a bacterial rather than viral pneumonia?
- coryzal symptoms
- Fever 38 degrees
- Generalised crackles
- Grunting
- Wheeze
Grunting
- resp distress including grunting suggests a bacterial pneumonia, bloods and antibiotics should be considered
does stridor suggest upper or lower airway obstruciton
suggets upper airway obstruction
What is DKA? characterised by what 3 things? what values?
Metabolic emergency: occurring in type 1 diabetes characterised by:
- acidosis (pH <7.3)
- ketoanaemia (blood ketones > 3 mol)
- Hyerglycaemia (>11mmol/l)
what are 3 important complications to keep in mind with DKA?
- Cerebral oedema
- Hypokalaemia
- Aspiration pneumonia
describe the pathophysiology of DKA? describe the hormones involved
autoimmune destruction of pancreatic beta cells => absolute deficiency of insulin => increased counter-regulatory hormones (glucagon, cortisol, catecholamines, GH) => hyperglycaemia + gluconeogenesis => ketones
why does DKA cause dehydration? explain physiology
hyperglycaemia => glycosuria => osmotic diuresis => polyuria => dehydration
describe the clinical features of DKA
- generally unwell, lethargic, abdominal pain
T1DM symtoms
- weight loss
- polyuria
- polydypsia
What would you find on examination of a child in DKA (ABCDE)
- Signs of resp compromise (deep/sighing breathing, tachypnoea, subcostal/intercostal recession)
- Circulatory compromise: Shock (tachycardia, hypotension, increased cap refill, cool peripheries), dehydration (dry mucus membranes, sunken eyes/fontanelles, reduced skin turgor)
- GI signs: abdo pain
- Neurological compromise
What are the sings of cerebral oedema? what could it be a complication of?
(possible complication of DKA)
- irritability, slowing pulse, rising BP, reduced consciousness
(cushing’s triad I think)
What investigations would you do in a patient with suspected DKA?
- Bedside blood glucose + ketones from finger prick
- Blood gas, blood glucose, U+E, FBC, creatinine (may show renal impairment)
Paeds DKA management
- Administer high flow oxy via non-rebreathe mask
- Gain IV access: initial bolus + ongoing fluids
- IV insulin + potassium replacement: wait a couple hours for this
Describe the fluid management for paeds DKA?
- Resuscitation fluids: bolus given to patients with shock
- Deficit fluids: calculated from the assumed dehydration level based upon the pH at presentation (10mL/kg 0.9% sodium chloride given to those presenting without shock) (kg x % x 10)
- Maintenance fluids: (100mL/kg/d for first 10kg; 50mL/kg/d for the next 10kg; 20mL/kg/day thereafter up to 80kg max) 0.9% sodium cholrodi with 20mmol potassium chloride in each 500 mL bag
A parent brings their 6 month child to A+E describing an apparent episode of apnea, lasting about 10 secs. this has never happened before. On examination the child is alert and there are no obvious concerns. Which investigations should be performed?
- ECG
- perusal swab for pertussis
How do you manage children with Mild croup?
all children with croup are given single dose of oral dexamethasone
- then usually managed at home with paracetamol/ibuprofen to manage fever and pain
- safety netting advice given
A 8 year old child who presented with breathlessness has a 5cm left sided pneumothorax. A chest drain needs to be inserted. What is the anatomical landmarks for inserting a chest drain?
5th Intercostal space, Mid axillary line
(in the safe triangle)
A 7 month old girl is brought to A&E with poor feeding, inconsolable crying and a distended abdomen. The parents report seeing a red appearance to her stools. Which is the most appropriate imaging to order first? and what is the likely diagnosis?
intussusception - abdominal USS
More than 90% of SIDS deaths occur before babies reach:
6 months
( even though SIDS can occur anytime during a baby fist year, more than 90% of SIDS deaths occur before babies reach 6 months of age)
What is the most common sign seen on a Childs CXR following foreign body inhalation
unilateral hyperinflation
What is the most common cause of shock in paediatrics?
sepsis
state whether the following present with wheeze, stridor, both or neither:
Eipglotittis?
bacterial tracheitis?
foreign body aspiration?
Asthma?
( need to check this one is right actually)
Eipglotittis: Acute stridor
Bacterial Tracheitis: stridor or wheeze
Foreign body aspiration: stridor or wheeze
Asthma: wheeze
Bronchiolitis: wheeze
In which age group is a neutral head position desirable to open the airway?
Neonates
How much maintaence fluid do you give for the fist 10kg of body weight?
100ml/kg
what ph for mild moderate and severe DKA?
Mild: 7.2-7.3
Moderate: 7.1-7.2
Severe: <7.1
What are the two main differentials for stridor ?
- Croup
- Foreign body ingestion
what is eventually found to be the most common cause of a BRUE?
GORD
A child is admitted with DKA and is severely dehydrated. Their blood pressure is low and you would like to give them a fluid bolus. Their weight is 23kg. How much fluid should you prescribe in the bolus?
230ml
(10mL/kg 0.9% sodium chloride over 1 hour)
(childnot in shock)
What is suggested when there is a clinical sign of bronchial breathing? what causes this?
Pneumonia
This is caused by fluid in the alveoli reducing airflow into them, meaning the air moving through the bronchi is hear instead
The commonest cause of finger clubbing children is?
Cystic Fibrosis
A child presents with chronic, productive cough. What is the most common cause of bronchiectasis in children?
Cystic Fibrosis
