Paeds Flashcards
Paeds: History
Intro
- Clarify child’s name and age and anyone else present
PC and HPC
- Exclude acutely unwell child (dry/empty nappies, cold hands and feet, inconsolable crying)
ROS
- General: Weight loss, colour, sleep, fever
- Cardio: Anaemia, cyanosis, sweating, lethargy, SOB, faints
- Resp: SOB, coryza, sore throat, earache, wheezing, cough, snoring
- Gastro: diet, appetite, weight loss, abdominal pain, abdominal distension, bowel habit, vomiting
- Urology: urine output/wet nappies, dysuria, enuresis
- Neuro: fits, headaches, hearing, vision
- Skin: lumps, bumps, rashes
- Musk: Limp, abnormal gait, pain in limbs, swollen joints
PMHx
- Complications during pregnancy
- Complications during labour/birth? birth weight? delivery method?
- Neonatal complications
- Feeding OK (quantify)
- Previous admissions to hospital
- Current conditions (asthma, diabetes, epilepsy)
- Any allergies (including hayfever, eczema)
- Vaccines up to date? if not, why?
Developmental history
- Height and weight (growth chart, red book)
- Development (4 domains, gross motor, fine motor and vision, hearing and language, social emotional and behavioural)
Drug history
- Any medication? Including creams, inhalers, alternative/herbal remedies
Family HX
- Anything rin in the family, including diabetes, asthma, hayfever, eczema
- Family tree
- Consanguinuity
Social Hx
- Who else is at home?
- How are things at home?
- Anybody else ill at home?
- Any smokers in the house?
- School/day care? Who looks after them after school?
Adolescent questions (HEADS)
- Home/relationships. Any issues?
- Education/employment: any issues?
- Alcohol
- Drugs/smoking (tried? regular use?)
- Sexual: Orientation? Relationships? sexually active? STIs? Contraception? Menstrual Hx?
Comclusion/summary
- Anything else of concern
Paeds: examination (general)
General examination, from end of ‘bed’. Can guide further examination as necessary
- Demeanour: Content, irritable/agitated, inconsolable, still
- Colour: Pale, cyanosed, jaundiced, grey
- Obvious physical abnormalities
- Movement: playing, holding one limb funny
- Tone: Stiff, floppy, abnormal posture
Paeds exam: Cardio and resp
Cardio
- Temperature, perfusion, peripheral pulses, cap refill (chest)
- Cyanosis (fingers, lips, mouth) - also for resp
- Heart rate (higher in kids anyway)
- Heart sounds +/- murmurs
- Blood pressure (not often done in kids but worth asking for anyway)
Resp
- Breathing rate (again higher in kids)
- Increased work of breathing (accessory muscles, inter/subcostal recessions, tracheal tug)
- Chest deformities (Harrison’s sulcus in long standing asthma, anterior rib expansion in rickets)
- breath sounds (bronchial/vesivular, wheeze, stridor, crackles, silent)
- Lymph nodes
Paeds exam: Gastro, urogenital, neuro/development, skin, hydration
Gastro/Urogenital
- Inspect abdomen for distension, ask parents if they think it looks distended
- Hernias
- Organomegaly and masses/lymph nodes
- Genitalia (hypospadias, testicle in each sac)
Neuro/development
- Ensure they can move all 4 limbs (may need to improvise w/play)
- GALS screen (Gait, inspect, arms, legs, spine)
- May need to formally assess all 4 domains
Skin
- Need to expose child fully, especially younger children
- Colour (pale, cyanosed, mottles, flushed)
- Rashes and lesions
Hydration
- Small children especially have a high surface area to body weight and can dehydrate quickly
- Urine output (dry nappies)
- Colour, tone, cap refill, skin turgor
- fontanelle: Bulging or sunken in babies
ENT examination
Ears
- Mother holding child facing sideways, one hand holding head, other hand holding body
- Pull pinna up to straighten the ear canal, then left hand holding otoscope for left ear (and right for right), finger on cheek to stabilise
- Looking for erythema, wax, discharge, intact eardrum (or gromit), ear pain/tugging
Nose
- Child on mum’s lap, facing you. one hand on head, other holding body
- Inspect nose internally and externally for: skin creases and cracks and discharge, nasal patency, septal deviation, inflammation and polyps
Throat
- May need a spatula. BE QUICK
- Tonsils: size, colour, hydration, pus/discharge. Tongue: shape, size, texture (strawberry)
- Septic child, drooling, mouth held open. Could be epiglottitis. DO NOT INSPECT. could close airways, needs experienced anaesthetist to intubate
Newborn baby examination
General
- Skin (pallor, mottled, cyanosed, jaundiced, lesions)
- tone (watch baby moving)
- birth weight (+centile) and gestational age
Fontanelle
- bulging suggests increased intracranial pressure, could be late miningitis
Head
- Head circumference + centile
Eyes
- Red reflex (corneal opacity, retinoblastoma, cataracts)
Face
- Syndromic features, obvious abormalities, cleft lip
Mouth
- suck reflex, feel for cleft palate
Heart
- HR (110-160), murmurs
Chest
- RR (30-50), breathing (chest wall movements), resp distress
Abdomen
- Feel for organomegaly, should feel 1-2cm of liver edge
- Feel for any masses
Femoral pulse:
- weak - coarctation of aorta. Strong - PDA
Hips
- Barlow’s (adduct hips, push knees posterior, positive if noticable clunk to dislocate hip)
- Ortolani’s (abduct hip, push forwards to relocate hip, confirms positive barlow’s) both done for DDH
Spine
- Midline tuft of hair suggests spine bifida oculta
Genitalia
- Patent anus. normal morphology, testis in scrotum
Feet
- Talipes: positional or fixed
Primitive reflexes
- Moro: support baby, drop back and catch, arms should go out then in
- Rooting reflex: head turns to that side when cheek stroked
- Suck reflex: mentioned above
- Asymmetric tonic neck (fencing). turn neck one side, ipsilateral arm extends, other arm contracts
- walking reflex: baby will attempt to walk as it’s out down while upright
Paediatric vital signs and normal ranges
<1yrs: RR 30-40 HR 110-160 Systolic BP 79-90
2-5yrs: RR 20-30 HR 95-140, Systolic BP 80-100
5-12yrs: RR 15-20 HR 80-120 Systolic BP 90-110
>12yrs RR 12-16 HR 60-100 Systolic BO 100-120
Fluid status, Rx of dehydration and fluid maintenance
<5%, not clinically dehydrated
- Normal
- Rx: continue milk, encourage clear fluids
>5% clinically dehydrated
- altered consciousness, unwell, reduced urine output
- O/E: Tachycardia, tachypnoea, reduced tissue turgor, dry mucous membranes, sunken eyes
- Rx: continue feeds + 40ml/kg oral rehydration solution over 4hrs. May need NG tube. IV fluids if vomiting
>10% clinically shocked
- reduced consciousness, pale/mottled appearance, cold extremities
- Tachycardia, tachypnoea, hypotension, weak pulses, prolonged cap refil
- Rx: IV fluids (Normal saline, 20ml/kg bolus (unless DKA or cerebral trauma, give 10ml/kg, worried about cerebral oedema) + maintenance.
- Still shocked –> PICU
- Not shocked –> 100ml/kg IV saline over 4hrs.
Maintenance fluids
First 10kg: 100ml/kg/day OR 4ml/kg/hr
Next 10kg: 50ml/kg/day OR 2ml/kg/hr
>20kg: 20ml/kg/day OR 1ml.kg.hr
Paediatric developmental milestones
4 domains: 1) Gross motor, 2) fine motor and vision, 3) Hearing and speech & language, 4) Social, emotional and behavioural
Newborn
1) Fixed, flexed position. Head lag
2) Fixes and follows
3) Stills to voices, startled by loud noises
4) Smiles (6 weeks)
7-9 months
1) sits unaided, crawls
2) palmar grasp, moves objects hand to hand
3) turns head towards noise, polysyllabic babble
4) finger feeds. fear of strangers, separation anxiety
12 months
1) Walking with broad based gait
2) pincer grip (10 months), pointing
3) 2-3 words, recognises own name
4) Drinks from cup, waves
18 months
1) walking independently
2) immature pencil grip, draws random scribbles. shape slotting
3) 4-6 words, can point to two body parts
4) Helps with dressing, symbolic play, feeds with spoon
30 months
1) running and jumping
2) drawing lines and circles, 8 block tower
3) 3-4 word sentences. can understand 2 joined commands
4) parallel play. clean and dry
Development red flags and investigations
Any age - Maternal concern - Regression of previous skill 10 weeks - Not smiling 6 months - Persistent primitive reflexes - Persistent squint - Hand prefeence - little interest in toys/people 10-12 months - Not siting independently - no pincer grip - no 2-syllable babble 18 months - Not walking - Fewer than 6 words - persistent drooling or mouthing 2.5yrs - No 2-3 word sentences 4yrs - Unintelligible speech
Investigations
- full physical: genetic syndromes, hepatomegaly –> metabolic, cafe-au-lait spots –> Neurofibromatosis, Microcephaly at birth –> foetal alcohol syndrome), poor growth (endocrine/malnutrition)
- Chromosomal analysis
- Metabolic tests
- Brain imaging
- hearing test (mandatory for any hearing or language delay)
Describing paediatric rashes: Checklist
Type
- Macular (flat area of altered colour (small)
- Papulae (solid raised lesions, <0.5cm across)
- Maculopapular
- Patches (flat area of altered colour (large)
- Pustules (pus containing lesions, <0.5cm)
- Plaques (palpable raised scaling lesions, >0.5cm)
- Nodules (solid raised lesions, >0.5cm across w/deeper component)
- Commodones (plug in sebaceous follicle, either open (blackheads) or closed (whiteheads))
Surface (smooth or rough)
Epidermal changes (lichenification, scaling)
Size, shape, symmetry
Distribution
Colour and pigmentation
Nail/mucosal involvement
Paediatric rashes: non infective
Atopic eczema
- Itchy rash, typically face, trunk and flexor surfaces
- Common in 1st year of life, associated with asthma and hayfever
- Scratching –> excoriation, infection or lichenification
- Rx: Avoid precipitants. Emolients, anti-histamine creams, steroid creams, occlusive bandages all help
- Antibiotics and immune modulators if infected or severe
Infantile Seborrheic dermatitis
- “cradle cap”, red scaly eruption on scalp. Head, then face, neck, napkin area
- Progresses to thick, yekllow adherent layer
- Not itchy
- Common in first 2 months
- Rx: Emolients, sulphur and salicylic acid ointment, topical corticosteroids. Psychosocial (for parents)
Psoriasis
- Usually gutate, rarely before 2 years old, often following strep/via URTI
- Red-pink raised patches with silver-white scaling on trunk and upper limbs
- Rx: emollient, coal tar, dithranol, calcipotriol
Acne vulgaris
- Commonly 1-2 years vefore puberty. Due to blockage of sebaceous follicles
- Open and closed commodones, pustules, nodules, papules
- Face, neck, back and shoulders. Can leave behing scarring when it resolves
- Rx: Topical benzoyl peroxide, antibiotics if infected, retinoids. Systemic antibioptics or isotretinoin if needed
Urticaria
- Delayed hypersensitivity reaction, usually bite (e.g. tick, mite, bed bugs)
- Hives/wheals
- Itchy. Can cause secondary infection
HSP
- Boys > girls, usually 3-10 years old, following URTI
- Papular rash on buttocks, extensor surfaces or elbows and knees and ankles. Spares trunk
- Commonly associated with abdominal pain, periarticular oedema, glomerulonephritis, arthralgia
Paediatric rashes: Infective
Candida infection
- Causes and complicates nappy rash. Felxure sparing
- Satellite pustules
- Rx: Ensure good hygiene. anti-fungals
Molluscum contageosum
- Small, pearly papules. Caused by pox virus, when is released in infectious core of pustules
- Rx (not usually needed, often self limiting): Cryotherapy. Antibiotics to treat possible secondary bacterial infection
Scabies
- Caused by sarcoptes scabei, very itchy, worse at night or when warm. Ask about living conditions
- Affects palms, soles, between fingers and toes and axillae in young
- Rx: whole family, 5% permethrin cream or 0.5% malathoin lotion on whole body below neck for 12hrs, then remove
Ring worm
- Annular lesions, crusted edge, caused by dermatophyte fungus
- Severe, pustular annular form = kerion
- Rx: topical antifungal cream or systemic antifungal if severe. Treat source, often animals
Erythema multiforme
- Target lesions, can be bullous or vesicular, caused bvy mycoplasma pneumoniae, herpes simplex and other viruses or drugs
- Usually resolves spontaneously in a few weeks
Erythema nodosum
- Discrete, tender red lesions on shins. Caused by IBD, primary TB, strep, drugs
- Rx: Treat underlyig cause, compression, anti-inflammatory drugs
Erythema infectiosum
- Caused by parvovirus B19. initially slapped cheek appearance, progress to maculopapular rash on trunk and limbs
- Rash associated with fever, malaise, headaches, myalgia
- Can cause aplastic crisis in sickle cell or autoimmuine diseases
- Can cause hydrops fetalis and death of baby in newborns
Meningococcal septicaemia
- Classic, non-blanching purpuric rash, irregular sized lesions, whole body, lesions have necrotic core
- Typically associated with neck stiffness, photophobia, headache. Can be more non-specific (fever, malaise, lethargy, poor feeding, seizures, reduced consciousness, shock, later bulging fontanelle)
- Dx: lumbar puncture (turbid fluid, polymorphs, low glucose, high protein)
- Rx: Rapid IV cefotaxime
UK Vaccination schedule
2 months: 6in1 (DTaP/Hib/HepB), Men B, PCV, Rotavirus
3 months: 6in1, rotavirus
4 months: 6in1, Men B, PCV
12-13 months: Hib, Men B, Men C, MMR, PCV
2-8 years: Annual influenza vaccine
3-4 years: DTaP, MMR
12-13 years: HPV vaccine (girls)
14-18 years: DTaP (no pertussis), MenACWY
Vaccines for at risk groups
- BCG @ birth
- Hep B @ 1,2,12 months
Contraindications for vaccination
- Acute febrile illness
- Previous anaphylaxis to vaccine with same component/constituent components
- Egg allergy (influenza, yellow fever, tick-bourne encephalitis). MMR safe but can be done in hospital if preferred)
- Immunosuppression (If short term, delay the vaccine , if long term, just give the vaccine with caution)
Live attenuated vaccines (avoid if immunosuppressed)
- SM BOY (+ oral rotavirus)
- Salmonella (Oral typhoid)
- MMR
- BCG
- Oral polio
- Yellow fever
- Oral rotavirus
Screening in paediatrics
Antenatal:
- Maternal: Sickle cell, thalassaemia, infection (syphillis, HIV, Hep B, rubella), done at 8-12 weeks and 28 weeks
- Foetal anomily: Combined test (USS for nuchal translucency, Bloods for bHCG and PAPP-A) @ 11-14 weeks for Down’s risk. If high risk: CVS or Amniocentesis (CVS <14 weeeks, Amniocentesis >14 weeks)
- 20 week structural abnormality scan (placenta position, physical foetal abnormalitis, liquor volume, growth of foetus)
Neonatal:
- Newborn baby check within 48hrs
- Guthrie card (5-9 days old): Hypothyroid, CF, PKU, MCADD, sickle cell
- Newborn hearing tests (Otoauditory Emission testing, if abnormal, then Automated uditory Brainstem Response audiometry)
Before school entry
- Growth, hearing, vision
Paeds emergencies: Initial assessment
Airway: Obstructions, secretions, see-saw breathing
- Rx: Jaw thrust, neck protrusion (neutral for infants, sniffing for child), remove obstruction if safe
Breathing: RR, Symmetry, Wheeze/stridor, work of breathing
- Rx: Auscultate & monitor, give O2, support breathing
Circulation: Pulse (rate and volume), blood pressure, cap-refill
- Rx: give fluids or blood, defirilate if needed, chest compressions
Disability: Consciousness, pupils, posture
- Rx: AVPU/GCS, Co-lateral Hx: Epilepsy, diabetes, poisoning, seizures, trauma
Exposure
- Expose for secondary examination and analgesia
DO NOT EVER FORGET GLUCOSE
Paediatric BLS
1) Unresponsive?
2) Shout for help. Open airway
3) Not breathing normally?
4) 5 rescue breaths
5) No signs of life?
6) 15 compressions, 2 rescue breaths, REPEAT
Paeds choking management
Assess severity
If effective cough:
- Encourage cough until obstruction removed or situation progresses to unresponsive cough
If ineffective cough:
- If conscious: 5 back blows, 5 thrusts (chest >1yo, abdo >1yo), REPEAT
- If unconscious: Open airway, 5 rescue breaths, then start CPR
Paeds ALS
1) Unresponsive?
- ABC
- Start CPR (5 rescue breaths, then 2:15)
- Attach monitors and defibrillator
- Call resus team (if alone, do 1 min CPR first)
2) Assess rhythm
Shockable (VF/Pulseless VT)
- 1 shock (4J/kg)
- resume CPR for 2 mins
- back to assess rhythm
Non-shockable (PEA/Asystole)
- Resume CPR (2 mins)
- Back to assess rhythm
Return to spontaneous circulation
- Immediate post cardiac arrest Rx
3) Immediate post cardiac arrest Rx
- ABCDE approach
- Appropriate O2 and ventilation
- Investigate and treat underlying cause
- Temperature control (?therapeutic hypothermia)
- Take <10s to look for: 1) signs of life (movement, coughing, breathing), 2) pulse (>1yo carotic, <1yo brachial) 3) continue compressions if pulse <60
CPR advice
Ensure high quality (rate, depth, recoil) Plan things before stopping CPR Ensure O2 Consider advanced airway & capnography Continuous compressions if advanced airway Venous access IV adrenaline every 3-5 mins Consider reversible causes - Hypothermia - Hypovolaemia - Hypoxia - Hypo/hyperkalaemia - Thrombosis - Tamponate - Toxicity - Tension pneumothorax
Newborn life support
1) Remove wet towels and dry baby
- assess tone, breathing, heart rate
2) If gasping or not breathing:
- open airway
- 5 rescue breaths
- measure SpO2
3) If no increase in heart rate, look for chest movements
- If chest isn’t moving, consider 2 person airway control and repeat 5 breaths
- If/when chest is moving, if HR <60: CPR 3:1
4) Reassess every 30s, consider venous access and drugs if HR still slow
Acceptible SpO2 @ age:
- 60% @ 2 mins
- 70% @ 3 mins
- 80% @ 4 mins
- 85% @ 5 mins
- 90% @ 10 mins
ALWAYS ASK: DO YOU NEED HELP
Management of anaphylaxis
1) Is this anaphylaxis
2) ABCDE
3) Confirm diagnosis of anaphylaxis
- Sudden onset
- Life threatening Airway (swelling, hoarse voice), Breathing (rapid/wheeze), Circulation (pale/clammy)
- Usually skin changes
4) Call for help
5) lie flat, legs up
6) IM adrenaline
7) When possible:
- Establish airway
- High flow O2
- IV fluid challenge
- Chlorphenamine
- Hydrocortisone
8) Monitor
- SpO2, ECG, BP
9) Discharge after 6hrs monitoring
10) 3 day course of steroids and anti-histamines
11) Long term:
- Allergy clinic and patient education
- Epipen (high risk cases) +/- alert bracelet
- Anaphylaxis Rx plan
Drug doses (age/IM adrenaline (1:1000)/IM chlorphenamine/IM hydrocortisone/IV/IO fluid challenge
- <6YO/150mcg (0.15ml)/2.5mg/50mg/20ml per kg
- 6-12YO/300mcg(0.3ml)/5mg/100mg/20ml per kg
- > 12YO/500mcg(0.5ml)/10mg/200mg/20ml per kg
Asthma: Diagnosis
If <2 or no interval symptoms: Consider diagnosis of Viral Induced Wheeze
Diagnosis:
- Cough, wheeze, chest tightness, difficulty breathing
- Worse in morning or at night
- Exacerbated by exercise, pets/allergens, cold or damp air, laughter or emotions
- Doesn’t only happen during a cold
- Family or personal Hx of atopy (asthma/eczema/hayfever)
- Widespread wheeze on auscultation,
- Hx of lung function improvement after trial of Rx
If low probability
- More detailed investigation, consider other diagnosis
If medium probability
- If evidence of airway obstruction, do spirometry and look for change in FEV1 or PEF in response to bronchodilator. If responsive, likely asthma. If not, then probably not asthma
If high probability
- Trial Rx and assess response. Further tests if poor response
Severity of acute asthma (>5YO)
- If mixed features, go with most severe category
Moderate
- SpO2 >92%, PEF >50% predicted, RR<30, HR <125, able to talk
Severe
- SpO2 <92%, PEF 33-50% predicted, RR >30, HR >125, use of accessory muscles, too SoB to talk
Life threatening
- SpO2 <92%< PEF <33% predicted, Silent chest, poor respiratory effort, cyanosis, agitated, altered consciousness
Management of acute asthma: Hospital
Assess severity Moderate - 2-10 puffs beta2 agonist via spacer (start at 2 puffs/2 min, increase dose by 2 puffs each time up to 10 puffs according to response) - 30-40mg oral prednisolone - reassess within 1 hour
Severe
- O2 to get SpO2 up to 94-98%
- B2 agonist 10 puffs via spacer OR nebulised salbutamol 2.5-5mg OR nebulised terbutoline 5-10mg
- Oral prednisolone 30-40mg OR IV hydrocortisone 4mg/kg if vomiting
- If poor response, nebulised ipatropium 0.25mg
- Repeat B2 agonist AND ipatropium every 20-30 mins according to response
Life threatening
- Nebulised b2 agonist (sallbutamol 5mg OR terbitaline 10mg) AND nebulised ipatropium 0.25mg
- Oral prednisolone 30-40mg OR IV hydrocortisone 4mg/kg if vomiting
- Repeat bronchodilators every 20-30 mins
- Contact senior (PICU or paediatrician)
Assess response with HR, RR, SpO2, PEF If responding: - Continue bronchodilators 1-4hrs PRN - Ensure stable on 4 hourly Rx - Oral pred 30-40mg for up to 3 days
When discharged
- Ensure stable on 4 hourly Rx
- Review inhaler technique
- Review need for regular Rx and inhaled steroids
- Provide written action plan for future attacks
- Arrange follow-up according to local policy
Management of acute asthma: GP
Assess severity
Moderate
- 2-10 puffs b2 agonist via spacer (2 puffs, increase by 2 puffs every 2 mins up to max 10 puffs according to response)
- Consider 30-40mg oral prednisolone
- If poor response, arrange admission to hospital
Severe
- 10 puffs b2 agonist via spacer OR nebulised salbutamol 2.5-5mg OR nebulised terbutaline 5-10mg
- Oral prednisolone 30-40mg
- Assess response after 15 mins of b2 agonist. If poor response, repeat b2 agonist and arrange admission
Life threatening
- Nebulisers (salbutamol 5mg or terbutaline 10mg AND ipatropium 0.25mg)
- Oral prednisolone 30-40mg OR IV hydrocortisone 100mg
- Repeat b2 agonist w/O2 driven nebuliser
- Arrange immediate hospital admission
Good response
- Continue B2 agonist via spacer or nebs up to every 4 hours
- If symptoms not controlled, repeat b2 agonist and refer to hospital
- 3 days oral prednisolone 30-40mg
- Arrange follow-up appointment
Poor response
- Stay with patient until ambulance arrives
- Send written referral info and assessment
- O2 driven nebulised b2 agonist in abmulance
Reduce threshold for admission if:
- Late evening or night
- Recent hospital admission or previous severe attack
- Concern about social circumstances and ability to cope at home
Management of chronic asthma <5YO
1) SABA
2) SABA + low dose ICS (8 week trial)
- If symptoms don’t resolve, consider alternative diagnosis
- If symptoms resolve and come back within 4 weeks of trial ending, start low dose ICS
- If symptoms resolve and come back >4 weeks after, then repeat the trial
3) SABA + low dose ICS + LTRA
4) remove LTRA, refer for expert opinion
SABA = Short Acting B2 Agonist ICS = Inhaled CorticoSteroid LTRA = LeukoTriene Receptor Antagonist
Management of chronic asthma 5-16YO
1) SABA
2) SABA + low dose ICS
3) SABA + low dose ICS + LTRA
4) SABA + low dose ICS + LABA
5) SABA + MART (contains low dose ICS)
6) SABA + MART with moderate dose ICS
7) SABA + Either:
- MART with high dose ICS
- Another drug e.g. Theophylline
- Referral to expert
SABA = Short Acting B2 Agonist (salbutamol) ICS = Inhaled CorticoSteroid (Beclometasone) LTRA = LeukoTriene Receptor Antagonist (montelukast) LABA = Long Acting B2 Agonist (Salmeterol) MART = MAintenance Reliever Therapy (Budenoside with formoterol)
Management of paediatric DKA
Clinical Hx - Polydipsia, polyuria - Weight loss - Abdominal pain, vomiting - Weakness, confusion Signs - Assess hydration - Ketone smell on breath - Kussmaul breathing - Confused, lethargic, drowsy Biochemistry - Glucose >11, pH <7,3, ketones in blood or urine - Take blood for urea and electrolytes - Other tests if indicated CONFIRM DIAGNOSIS OF DKA, Call senior staff Assess hydration 1) Shock: Reduced peripheral pulse volume, reduced consciousness/coma - Airway +/- NG tube - Breathing: Aim for 100% SpO2 - Circulation: 10ml/kg 0.9% saline, repeat until haemodynamically stable, max 3 doses - This should then bring patient out of shock to just dehydrated (3)
2) Barely dehydrated (<5%), clinically well, tolerating oral fluid
- s/c insulin and oral fluids
- If no improvement, go to (3), otherwise keep monitoring
3) Dehydrated >5%, clinically acidotic, vomiting
- IV therapy:
- 0.9% saline, aim to correct fluids over 48hrs
- add 20mmol KCl per 500ml
- 0.1U/kg/hr insulin infusion after 1hr fluids
4) Observations
- Hourly blood glucose, ketones, fluid balance
- Electrolytes 2hrs after IV begins, then every 4 hours
- aim for glucose <14mmol/L
New neuro signs (if absent, move on to (5)
- E.g. headache, bradycardia, increased ICP, irritable, decreased consciousness
- Exclude hypoglycaemia. Could be Cerebral Oedema
- 5ml/kg 2.7% saline or 0.5-1g/kg mannitol
- Call senior help, consider PICU
- Reduce IV fluids by half
- CT scan when stable
Not improving (If improving, move on to (5)
- Monitor fluid balance
- Give IV therapy as per (3)
- If acidosis continues, may need more fluid resus
- Check insulin dose is correct
5) Glucose <14mmol/L
- Add 5% glucose to 0.9% saline
- Change to 5% glucose 0.45% saline after 12hrs
- Monitor as above (4)
- Reduce insulin to 0.05U/kg/hr if pH>7.3
6) Resolution of DKA
- Clinically well, drinking and tolerating food
- Blood ketones <1.0mmol or pH normal
- Urine ketones may be high for a while
7) Insulin
- Start sub cut, then stop IV 1 hr later
management of status epilepticus
1) Airway, High flow O2, Don’t Ever Forget Glucose
2) [5 mins after convulsions start] Vascular access?
- Yes? –> IV/IO lorazepam 0.1mg/kg
- No? –> Buccal midazolam 0.5mg/kg or rectal diazepam 0.5mg/kg
3) [10 mins later, still seizing]
- IV/IO lorazepam 0.1mg/kg
- Prepare phenytoin
4) [10 mins after (3)} Confirm it’s an epileptic fit
- Get senior help (Anaethetics/PICU)
- IV phenytoin 20mg/kg over 20 mins
- [5 mins later] If already on phenytoin, give IV/IO phenobarbitol 20mg/kg
5) [20 mins after (4)} Anaesthetics MUST be present
- RSI with thiopentane
Feverish child (<5 YO): Traffic Light System
COLOUR Green - Normal; skin, lips and tongue Amber - Pallor reported by parent/carer Red - Pale, mottled, ashen or blue ACTIVITY Green - Responsive to social cues, awake or quickly aroused - Content/smiling, strong normal cry/not crying Amber - Not normal response to social cues - Wakes only upon prolonged arousal - Decreased activity/no smile Red - Unresponsive to coal cues. Looks unwell to HCP - Unable to awake or if roused, only awake for short time - Weak, high pitched or continuous cry RESPIRATORY Green - No amber or red signs Amber - Nasal flairing - Crackles on auscultation - RR>50 (<12m) or >40 if >12m. SpO2<95% on air Red - Grunting - Moderate or severe chest indrawing - RR>60 HYDRATION Green - Moist mucous membranes, normal skin and eyes Amber - Dry mucous membranes, cap refill >3s - Reduced urine output - Poor feeding in infants Red - Reduced skin turgor OTHER Green - No amber or red Amber - Fever > 5 days - New lump >2cm -Swelling of limb or joint - Not wiehgtbearing or using one limb RED - T>38 (0-3 months) or T>39 (3-6 months) - Bile stained vomiting - Non-blanching rash - Bulging fontanelle - Neck stiffness - Focal neurological signs - Focal seizure - Status epilepticus
