Paeds EMERGENCIES Flashcards
Recall 2 causes of neonatal collapse
Sepsis
CHD
Recall 4 possible causes of jaundice in the neonate
Breast milk
Sepsis
Feeding difficulty
Physiological
Recall 4 common causes of rash in the neonate
Nappy rash
Milia
Erythema toxicum
Mongolian blue spot
Recall 2 causes of seizures in the neonate?
Hypoglycaemia
HIE
What colours of skin would be a red flag in the traffic light system?
Pale/ mottled/ ashen/ blue
At what age is a child with fever always considered a red flag in the traffic light system?
<3 months
Recall how CPR differs in adults compared to children and neonates
Adults: 30:2
Children: 15:2
Neonates: 3:1
In the ABCDE formulation, what comes under ‘disability’?
AVPUG - Alert, voice, pain, unresponsive, glucose
What is the most common surgical emergency in newborn babies?
Necrotising enterocolitis
Describe the decorticate and decerebrate positions
Decorticate = bending wrists up to neck
Decerebrate = wrists pointing out, arms straight down by sides
What is SIRS?
Generalised inflammatory response, defined by >/= 2 criteria:
Must inculde 1 of:
- Abnormal temp (<36, >38.5)
- Abnormal WCC
The other criteria are:
- Abnormal HR
- Raised RR
How is a high risk sepsis diagnosed?
CVS: hypotension, prolonged cap refil, O2 needed to maintain SpO2
Blood lactate >2
Pale, mottled or non-blanching purpuric rash
RR abnormal or grunting
What is the sepsis 6 pathway in adults?
Oxygen
Blood + blood cultures
IV Abx
IV fluids
Check serial lactates
Check urine output
What is the difference between Sepsis and SIRS?
Sepsis = SIRS with infection
How is severe sepsis defined?
Sepsis with CV dysfunction, ARDS or dysfunction 2 or more organs
How is septic shock defined?
Sepsis with CV dysfunction persisting after >, 40mL/kg of fluid resuscitation in 1 hour
What are the common organisms implicated in early onset neonatal sepsis?
Group B streptococcus (most common gram +ve)
E coli (most common gram -ve)
L monocytogenes
Which organism is most likely to cause late onset neonatal sepsis?
Coagulase-negative staphylococcus (CoNS) eg. Staph. Epidermis
Which children with sepsis should have an LP?
<1 month old
1-3 months who appear unwell/ have WCC <5 or >15
What is the sepsis 6 pathway in children?
Give:
1. High-flow O2
2. Abx
- Early-onset neonatal = cefotaxime, amikacin + ampicillin
- Late-onset neonatal =meropenem+ amikacin + ampicillin
- >3m old = ceftriaxone)
3. Early senior input
4. Early inotropic support
5. Fluid resus if indicated (20mls/kg 0.9% NaCl over 5-10 mins)
Take:
1. Bloods:
FBC (abnormal WCC?)
U&E + CRP (?urosepsis)
Glucose
Clotting (?DIC)
ABG + lactate
Which Abx are most useful in meningococcal sepsis?
IM benzylpenicillin (in community)
or
IV cefotaxime (in hospital)
Which Abx are most useful in early onset neonatal sepsis?
Most likely to be GBS, L. monocytogenes or E coli so:
IV cefotaxime + amikacin + ampicillin
Which Abx are most useful in late onset neonatal sepsis?
Most likely to be CoNS (s. epidermis) so:
IV meropenem + amikacin + ampicillin
What is opisthotonos?
Hyperextension of neck + back
What are the two ‘signs’ indicative of meningitis?
Kernig’s sign: pain on leg straightening
Brudzinski’s sign: supine neck flexion –> knee/ hip flexion
What type of rash is often present in meningitis and what type of meningitis is this most common in?
Non-blanching: meningococcal
How does the HR change throught the course of illness in meningitis?
Starts high to compensate for brain ischaemia, then drops to as baroreceptors sense high BP
What symptoms make up Cushing’s triad of high ICP?
High BP
Low HR
Irregular RR
In what order should meningitis investigations be done?
First: LP if not contraindicated to identify source of infection
Next:
1. VBG: including glucose + lactate
2. Blood cultures (BEFORE empirical abx started)
3. FBC, CRP, U+E and creatinine
(After this: give broad spec abx at highest possible dose without delay)
As well as sepsis 6 pathway + Abx, what should the management be in meningitis in children?
Steroids (dexamethosone) if CSF shows purulent CSF, WBC >10000, WCC + protein >1g/L, bacterial gram stain + ONLY if it’s not meningococcal
Mannitol (to reduce ICP)
IV saline NaCl
What potential longterm complications of meningitis might need to be discussed with a child’s family?
Hearing loss, renal failure, neurodevelopmental conditions
Purpura fulminans: haemorrhagic skin necrosis from DIC
What are the most common causes of viral meningitis?
Coxsackie Group B
Echovirus
What is encephalitis?
Inflammation of the brain parenchyma
What are the 3 possible aetiologies of encephalitis?
- Direct invasion of cerebellum (eg HSV)
- Post-infectious encephalopathy = delayed brain swelling following neuroimmunological response to antigen
- Slow virus infection (eg HIV or SSPE following measles)
What are the signs and symptoms of encephalitis?
Same as meningitis: might not be able to tell the difference clinically! If behavioural change is more likely to be encephalitis
What are some contraindications for LP?
Cardiorespiratory instability
Signs of raised ICP
Thrombocytopaenia
Focal neurology
Coagulopathy
Meningococcal meningitis
How should encephalitis be managed?
IV acyclovir (high dose) for 3 weeks
HSV is a rare cause but complications are major so treat empirically
What should be added to the treatment regime if it’s a CMV encephalitis?
Ganciclovir + Foscarnet
What is anaphylaxis?
W
IgG cross-linking with IgE membrane-bound Ab of mast cell/ basophil
What is the most common cause of anaphylaxis in children?
Food allergy (85%)
What is the dose of IM adrenaline in paediatric anaphylaxis?
1:1,000
When can a repeat dose of IM adrenaline be given in paediatric anaphylaxis treatment?
If response after 5 mins is insufficient
After giving adrenaline, how should anaphylaxis be managed?
Establish airway + high flow O2
IV fluids (crystalloids)
IV chlorpheniramine
IV hydrocortisone
Salbutamol if wheeze
What is the first thing that must be done on observation of a dry baby at delivery?
Note time!
What must be done within the first 30 seconds of a neonatal resuscitation?
Assess tone, RR, HR (femoral + brachial) + colour
What must be done within the first 60 seconds of a neonatal resuscitation?
If not breathing, open airway, do 5 INFLATION BREATHS
Reassess + repeat until chest movement seen
Once chest movement is seen in a neonatal resuscitation, what should be done next?
Ventilate for 30s
Then chest compression + ventillation with a rate of 3:1
If HR remains undetectable/ slow in a neonatal resuscitation, what should be considered?
Consider venous access + drugs
When should the Apgar score be used?
At 1 + 5 mins after delivery, + every 5 mins after if condition remains poor
What apgar score is considered normal?
> 7
What are the components of the apgar score?
Appearance (colour)
Pulse
Grimace
Activity (muscle tone)
Respiratory
What should be considered if, after tracheal intubation, HR does not increase and good chest movement is not achieved in a neonatal resuscitation?
DOPE:
Displaced tube
Obstructed tube
Patient (tracheal obstruction? Lung disorder? Shock? Choanal atresia?)
Equipment failure
When should 5 rescue breaths be given in paediatric BLS?
DR AB RESCUE BREATHS CDE
At what BPM should chest compressions be done in paediatric BLS?
100-120
What is one thing to be cautious of if delivering high oxygen levels to a neonate?
Retinopathy of prematurity
Recall some signs of respiratory distress in babies
High RR (>60)
Laboured breathing
Chest wall recessions
Nasal flaring
Expiratory grunting
Cyanosis (if severe)
What is the most common cause of respiratory distress in term infants?
Transient tachypnoea of the neonate
Recall 4 conditions that PPHTN can be secondary to
Birth Asphyxia
Meconium aspiration
Septicaemia
RDS
What is the pathophysiology of PPHTN?
High pulmonary vascular resistance –> right to left shunting within lungs at atrial and ductal levels
Recall some signs and symptoms of PPHTN
Cyanosis after birth
Absent heart murmurs + signs of HF
What investigations are appropriate in PPHTN and what would they show if pos?
CXR: normal heart size but some pulmonary oligaemia
Echo: to ensure no cardiac defect
How should PPHTN be treated?
Oxygen, NO (inhaled), sildenafil (!!) Ventilation: mechanical, high frequenct (oscillatory) OR, if severe, extracorporeal membrane oxygenation (ECMO) +/- heart/lung bypass
What is the cause of TTotN?
Delay in resorption of lung fluid
How is a diagnosis of TTofN made?
- CXR - shows fluid in horizontal fissure
- Other causes excluded
What is the cause of pneumothorax in children, and what is the best way to prevent them?
Ventilation which causes pulmonary interstitial emphysema
Can be prevented that infants are ventilated on the lowest possible pressures with adequate chest movement and blood gaes
How should infant pneumothorax be treated?
Immediate decompression
Oxygen therapy
Chest drain if tenion pneumothorax
What is billious vomit a red flag for?
Intestinal obstruction (intussusception, malrotation, strangulated inguinal hernia)
What is haematemesis a red flag for?
Oesophagitis/ PUD
What is projectile vomit at 2-7 weeks a red flag for?
Pyloric stenosis
What is vomiting at end of paroxysmal coughing a red flag for?
Whooping cough
What is abdo distention a red flag for in a baby?
Intestinal obstruction
Strangulated inguinal hernia
What is hepatosplenomegaly a red flag for?
Chronic liver disease
Inborn error of metabolism
What is blood in stool a red flag for?
Intussusception
Gastroenteritis (salmonella, campylobacter)
What are bulging fontanelles/ seizures a red flag for?
Raised ICP
What is a failure to thrive a red flag for?
GORD
Coeliac
Chronic GI
What is chronic vomiting in an infant most likely to be due to?
GORD or a feeding problem
What is transient vomiting in a child most likely to be due to?
Gastroenteritis
URTI
What needs to be excluded urgently when an infant is vomiting?
Meningitis
UTI
What is a failure to pass meconium in first 24 hours a red flag for?
Hirschprung’s
What is FTT/ growth failure a red flag for in a constipated child?
Hypothyroid/ coeliac
What is gross abdo distention with constipation a red flag for?
Hirschprung’s/ other GI dysmotility
What is abnormal LL neurology/ deformation a red flag for?
Lumbosacral pathology
What is a red flag for spina bifida?
Sacral dimple above nasal cleft
What is perianal fistula/ abscess/ fissure a red flag for in infants?
Perianal Crohn’s
Recall the management protocol for paediatric status epilepticus
- ABC
- Check blood glucose - if <3mmol/L –> IV glucose and then re-check
- If vascular access –> IV lorazepam
If no vascular access –> PR diazepam/ buccal midazolam - If IV access: More lorazepam
If still no IV access - PR paraldehyde - If previously had IV access to give IV lorazepam but it hasn’t worked, try PR paraldehyde
- If no response in 10 mins call for senior help
If not on oral phenytoin: phenytoin
If already on oral phenytoin: phenobarbital - If no response within 20 mins, call anaesthetist/ intensivist –>
Induction with thiopental
Mechanical ventilation
–> PICU
What is the dose per kg of lorazepam to give to children in status epilepticus?
0.1mg/kg
What is the dose per kg of diazepam to give to children in status epilepticus?
0.5mg/kg
When should an LMA adjunct be used?
In babies weighing over 2kg and over 34 weeks.
How is perinatal hypoxic ischaemia managed?
Therapeutic hypothermia - temp decreased down to 33 degrees for 3 days.
Associated with a small reduction in long-term disability.
