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4th Year > Paeds - emergency (ppt) > Flashcards

Paeds - emergency (ppt) Flashcards

1
Q

1) 10 year old girl presents with a 1 day history of a red swollen eye.

What would make you suspect allergic or bacterial conjunctivitis?

A

Allergic conjunctivitis:

  • ocular itching is prominent
  • bilateral conjunctival redness + swelling
  • hx of exposure then symptoms

Bacterial conjunctivitis:

  • redness + discharge from one eye
  • affected eye “stuck shut” in the morning
  • bacteria (s.aureus, h.strep, h.influenzae), chlamydia, viruses
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2
Q

1) What is the difference between pre-septal and orbital (post-septal cellulitis)?

A

Pre-septal = inflammatory disease of the orbit limited to the tissues anterior to the orbital septum

Orbital cellulitis = inflammatory disease of superficial and deep structures of the orbit

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3
Q

1) When would you suspect pre-septal and orbital cellulits and how would they present?

A

Commonly follow URTI and sinusitis (ethmoid usually).

  • or spread from skin, lachrymal ducts, middle ear, etc.

Commonly Streptococcus, Haemophilus.

Orbital cellulitis presents with red flag features…

  • cannot sufficiently open eye to examine
  • lid/tissue erythema (pre-septal too)
  • conjunctiva appears swollen/infected
  • visual acuity is impaired
  • eye movement is impaired/ painful
  • proptosis is present
  • pupillary reaction is asymmetrical/ relative afferent pupillary defect
  • systemically unwell, fever

Pre-septal cellulitis would present systemically well and negative on all the above findings, except the lid and tissue can be erythematous.

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4
Q

1) How would you manage pre-septal and orbital cellulitis?

A
  • Admit
  • IV access
  • FBC, CRP, blood cultures
  • Nose swab
  • IV ceftriaxone (+/- IV metronidazole if sinuses involved)
  • ENT and Opthalmology review
  • 4 hourly obs
  • consider a CT scan
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5
Q

2) An 8 year old girl presents to ED with fever, headache, neck stiffness

what would you consider?

A
  • bacterial meningitis
  • viral meningitis
  • viral encephalitis
  • tuberculous meningitis
  • cerebral abscess
  • hydrocephalus
  • non-accidental injury

If bacterial meningitis is considered, do A-E and LP/Sepsis 6

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6
Q

2) What are some contradictions to an LP

A
  • cardiorespiratory instability
  • signs of raised ICP (coma, low hr, high bp, papilloedema, bulging of fontanelles) = do a CT
  • Coagluation abnormalities, thrombocytopaenia
  • make sure they are stabilised after seizures
  • focal neurological signs
  • signs of infection at the LP site
  • concerns about meningococcal septicaemia (do not delay sepsis 6!!!)
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7
Q

2) how would you manage bacterial meningitis after A-E?

A

(Bolded the definite. others are adj)

<28 days = 3rd gen ceph (cefotaxime/ceftriaxone) + amoxicillin + gentamicin

<3 months = IV amoxicillin + IV cefotaxime

>3 months = 3rd gen cephalosporin + amoxicillin (for Listeria) + acyclovir (until microbiology seen)

If recent travel = vancomycin + cefotaxime

  • Call for senior help!!!
  • Hearing test within 6 weeks of presentation
  • IV fluids (2/3 if SIADH = low serum Na, high urine Na)
  • mechanical ventilation if resp impairment
  • consider CT scan for other intracranial pathologies
  • Rifampicin for close contacts (kids)
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8
Q

2) What are some complications of bacterial meningitis?

A

Acute

  • septic shock
  • DIC due to sepsis and coagulopathy
  • Raised ICP due to cerebral oedema (raised BP, low hr, low GCS)
  • SIADH = fluid retention and decreased serum Na
  • Hydrocephalus (obstruction from oedema/infection)
  • cerebral abscess/ subdural empyema

Long term

  • hearing loss due to damage to cochlear hair cells
  • local vasculitis
  • local cerebral infarction = seizures, epilepsy
  • subdural effusion (common in infants, can cause bulging fontanelle, enlarged head, seizures)
  • learning difficulties, developmental deficits
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9
Q

3) A 2 year old girl presents to ED with a barking cough and noisy breathing

What would you consider?

A

Differentials:

  • viral croup
  • Acute infections…
    • epiglottitis
    • bacterial tracheitis
    • diptheria
    • peritonsillar or retropharyngeal abscesses
  • Non-infections…
    • foreign body
    • anaphylaxis
    • burns
    • angioedema
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10
Q

3) What would make you suspect viral croup?

A
  • common cause of laryngotracheal infections
  • Triad of hoarse voice, barking cough, stridor, +/- fever
  • between 6 months- 6 years old (peak at 2 years old)
  • Commonly parainfluenza virus
    • then influenza virus, RSV, adenovirus, measles
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11
Q

3) What is the difference between stridor and wheeze?

A

Stridor

  • high pitched, high energy inspiratory sound
  • due to turbulent airflow over upper airway
  • expiratory with severe upper airway or tracheal narrowing

Wheeze

  • high pitched, whistling expiratory sound
  • suggests narrowing of l_ower airways_

Stertor

  • low pitched, high energy snoring sound
  • due to nasal obstruction, tonsil/ adenoid hypertrophy and neuromuscular weakness
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12
Q

3) How would you manage viral croup?

A

classify it via Westley Croup Severity Score

  • give points based on level of consicousness, cyanosis, stridor, air entry, retractions

Mild = <4

  • occasionally barky cough, no stridor, no/mild retractions
  • give oral dexamethasone (0.15mg/kg)
  • <2 discharge home, otherwise observe for an hour

Moderate = 4-6

  • frequent barky cough, stridor at rest, mild/mod retractions, no/little distress
  • prompt senior review
  • oral dexamethasone or neb budesonide (2mg) if cannot have oral
  • O2 if spo2 <92%

Severe = >6

  • frequent barky cough, stridor at rest, marked retractions, significant distress/agitation
  • prompt senior review
  • neb adrenaline (0.4mg/kg) of 1:1000 sol
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13
Q

3) when would you suspect epiglottitis as opposed to croup?

A
  • commonly caused by haemophilus influenzae
  • onset over hours (croup = over days)
  • no preceding coryzal symptoms (croup has)
  • appearance is very unwell, anxious, irritable, restless (only severe croup)
  • Temp >38.5C (Croup <38.5C)
  • Severe sore throat (more severe than croup)
  • Unable to drink (croup can drink)
  • Drooling (not significant in croup)
  • absent or slight cough (croup has barking severe cough)
  • soft whispering stridor (croup has harsh, rasping stridor)
  • muffled reluctant voice (croup has hoarse voice)
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14
Q

4) A 3 year old boy presents to ED with a fever and rash

What are some differentials?

A

Measles

  • caused by RNA paramyxovirus
  • incubation - 10 days to fever, 14 days to rash
  • pyrexia, maculopapular rash, Koplik spots, conjunctivitis and coryza, cough

Roseola infantum

  • typically in kids 6 months- 2 years old
  • 3-4 days of fever and malaise
  • widespread maculopapular rash when fever subsides

Rubella

  • incubation 15-20 days
  • low grade fever or none, widespread maculopapular rash spreading from face
  • prominent lymphadenopathy (sub-occipital, post-auricular)

Slapped cheek syndrome

  • parvovirus B19
  • fever, malaise, headache, myalgia
  • maculopapular rash appears on face a week later, then spreads to trunk and limbs

Scarlet fever

  • diffuse blanching erythema, raised papules (sand paper feel) starting at the groin and axilla, spreading to trunka nd extremities
  • associated with strawberry tongue
  • generally associated with pharyngitis (Strep A)
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15
Q

5) A 3 year old boy presents to ED with a fever and non-blanching rash

What would you consider?

A

Meningococcal septicaemia

  • Risk factors = winter, smoking, preceding influenza A infection, living in closed/semi-closed community
  • commonest serotypes in the UK = B,C,W,Y

Clinical presentation

  • incubation period 2-7 days
  • coryzal symptoms, fever, poor feeding, vomiting, diarrhoea, headache, irritable, drowsy, seizures, rash in 80%
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16
Q

5) How would you manage meningococcal septicaemia in primary care, then in hospital

A

Pre-hospital

  • IM Benzylpenicillin
  • High flow O2
  • call blue light ambulance

Emergency care

  • notify ICU and anaesthetists pre-arrival
  • rapid A-E
  • high flow O2
  • IV access = bloods, IV ceftriaxone, IV fluids
  • Early inotrope support
  • Early airway support
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17
Q

6) a 6 year old boy presents to ED with an acute antalgic gait

What would you consider?

A
  • Transient synovitis
  • septic arthritis
  • osteomyelitis
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18
Q

6) How would you differentiate transient synovitis vs septic arthritis?

A
  • both present with an acute limp
  • TS will look well, SA looks very unwell
  • TS has normal or low grade temp, SA is pyrexic
  • TS is mild pain, SA is mod/severe pain even at rest
  • Hip US shows fluid in the joint in SA (may show it for TS too)

Modified Kocher Criteria show increasing likelihood of SA

  • Fever >38.5C
  • WCC >12x10^9 /L
  • CRP >20
  • Inability to weight bear
  • if patient has all 4 there is a 99.6% of SA
19
Q

6) How would you investigate the acute limp

A
  • FBC, CRP, blood cultures
  • Xray
  • US for joint effusion (SA)
  • Synovial fluid before antibiotics (G stain to help antibiotic choice)
    Surgical referral for pus drainage helps treatment
20
Q

6) What are some pitfalls to be aware of when diagnosing acute limp?

A
  • failure to diagnose previous limps can result in missing chronic disease eg. DDH, Perthes, JIA
  • incorrect joint identification eg. diagnosing knee pain not hip pain
  • giving antibiotics before obtaining culture samples
  • failure to identify bone as source of pain eg. malignancy, leukaemia
  • not examining abdo, missin intraabdo causes of “hip pain” eg. appendicitis
  • not examining testicles and missing testicular torsion
  • not checking for lymphadenopathy, hepatosplenomegaly or pallour (haematological malignancy)
21
Q

7) child comes in with a 2 week history of a limp

What are some differentials for an atraumatic limp?

In a toddler, child 5-9, adolescent >10

A

Toddler 1-4

  • transient synovitis
  • toddlers fracture
  • DDH
  • non-accidental injury

Child 5-9

  • transient synovitis
  • Perthes disease
  • Juvenile Idiopathic Arthritis

Adolescent >10

  • slipped capital femoral epiphysis
  • JIA

ALSO Consider…

  • infections like osteomyelitis, myositis, discitis
  • Sickle cell disease
  • Acute lymphoblastic leukaemia or other malignancies
  • Lower abdo or inguinoscrotal pathology eg. appendicitis, testicular torsion
22
Q

8) 6 year old presents to ED after a suspected allergic reaction

What should you be sure to ask in the history?

A
  • trigger? = food, drug, sting, contact
  • time between exposure and symptoms
  • location and activity at time of episode
  • PMH = recent illness eg. URTI, prev allergy or anaphylaxis
  • associated allergy eg. eczema, rhinitis, asthma
  • symptoms eg. skin, gut, resp, CVS
    • Gut = food poisoning, gastroenteritis
    • Resp = URTI, irritant rhino-conjunctivitis, choking, viral wheeze, acute asthma exacerbation
    • CVS = vasovagal syncope, panic attack
  • urticaria or angioedema?
23
Q

8) How would you define anaphylaxis?

A

severe, life-threatening allergic reaction that is acute in onset and can cause death.

  • acute onset (mins-hours) involving skin, mucosa or both (urticaria, angioedema) + atleast ONE of…
    • Resp compromise (dyspnoea, wheeze, stridor, hypoxaemia, reduced PEF)
    • Reduced BP or end organ dysfunction eg. syncope, incontinence, hypotonia
  • 2 or more of the following mins-hours after exposure to likely allergen for that patient
    • skin or mucous membrane involvement
    • resp compromise
    • CVS compromise
    • persistent gi symptoms eg. crampy abdo pain, vomiting
  • Reduced BP after exposure to known allergen for that patient
    • infant/child = >30% drop
    • adolescent = <90mmhg or >30% drop
24
Q

8) What is emergency management for anaphylaxis in community

A

Community

  • stay with child, call for help
  • lie child with leg raised, if difficulty breathing sit them up
  • give adrenaline autoinjector
    • pull off blue safety cap (hold it blue to sky, orange to thigh)
    • hold orange end against mid outer thigh and push down until a click
    • hold for 3s and remove EpiPen
    • do not stand child up
    • if no improvement after 5 mins, give another adrenaline
  • give antihistamine
25
Q

8) What is emergency management for anaphylaxis in hospital?

A
  • call for help, remove allergen
  • high flow O2 via facemask
  • IM adrenaline at mid lateral thigh
  • lie flat on back with knees up
  • Assess airway
    • partial obstruction = repeat IM adrenaline, neb adrenaline, hydrocortisone IV
    • complete obstruction = call anaesthetist, intubation or surgical airway
  • Assess breathing
    • wheeze = repeat IM adrenaline, neb salbutamol, hydrocortisone IV, salbutamol IV
    • apnoea = bag/mask ventilation, repeat IM adrenaline if no response, hydrocortisone
  • Assess circulation
    • shock = repeat IM adrenaline, IV fluid bolus, consider IV adrenaline
    • no pulse = BLS algorithm
26
Q

9) 2 year old presents to ED after a suspected allergic reaction

  • Woke up this morning with the rash (raised erythematous plaques, some have pale centre, plaques are coalescing)
  • rash is very pruritic
  • toddler is agitated, irritable, unhappy
  • no previous allergies
  • no recent new contact

What would you suspect and what would you do?

A

Urticaria

  • intensely pruritic erythematous plaques
  • may be associated with angioedema (swelling)
  • Acute = <6 weeks, triggers allergy, URTI, idiopathic
  • Chronic = >6 weeks, spontaneous or physical triggers

Management

  • if new onset acute urticaria where assessment does not suggest underlying cause = no investigations
    • fbc and crp if worried about vasculitis
  • high dose non-sedating antihistamines + glucocorticosteroids
    • 1st gen antihistamines are sedating = chlorphenamine, diphenhydramine, hydroxyzine
    • 2nd gen are non-sedating = cetrizine, loratadine, fexofenadine, desloratadine
27
Q

10) a 14 year old has come in after reported intentional ingestion of paracetamol

what would you do? hx, management.

A

Hx

  • dose?
  • timing?
  • associated ingestions?

Admit if…

  • ingested paracetamol for self harm
  • symptomatic
  • >75mg/kg of paracetamol ingested (within <1hour or where time frame is unknown)

If ingestion was <1hour ago AND >150mg/kg, give oral charcoal and IV anti-emetic

Delay sampling to 4 hours after ingestion

  • take paracetamol blood level
  • U&Es (baseline renal status, risk of aki)
  • LFT (monitor ALT for hepatotoxicity)
  • glucose (hypoglycaemia is common in liver necrosis)
  • clotting screen (INR and PT to indicate liver necrosis)
  • venous gas (acidosis can indicate acute liver failure)

Give N-acetylcysteine infusion

  • most effective at reducing severity of liver damage if given within 8 hours of overdose (can be give up to 24hrs)
  • give to patients who present within 24 hours of an overdose if tests suggest acute liver injury (even if plasma paracetamol conc is lower than treatment line on paracetamol treatment graph)
28
Q

11) a 3 yaer old is rushed into ED with a generalised seizure

What are some differentials you need to consider?

A
  • Febrile convulsions
  • known epilepsy or acute illness
  • meningitis or encephalitis
  • hypoglycaemia, hypocalcaemia
  • metabolic/ poisoning
  • trauma = accidental or non-accidental
29
Q

11) How would you manage a patient with generalised seizures?

A
  • A-E asap
  • within 5 mins of start of fit –> IV access?
    • yes = lorazepam IV
    • no = buccal midazolam or rectal diazepam
  • Monitor once they stop fitting
  • If they are still fitting in 10 mins, give lorazepam IV
    • can give paraldehyde PR
  • If they are still fitting in 10 mins, give phenytoin IV/IO and phenobarbitone IV/IO (both are infusions over 20 mins)
  • If they are still fitting in 10 mins, this is status epilepticus (>30mins)
    • do Rapid Sequence Induction (RSI) with thiopentone
30
Q

12) An 18 month old presents with sickness and diarrhoea

What are some features of clinical dehydration and shock you need to look out for?

A

Clinical dehydration

  • appears unwell or deteriorating
  • drowsy and altered responsiveness
  • reduced urine output
  • dry mucous membranes
  • warm extremities
  • sunken eyes
  • reduced skin turgor
  • tachycardia
  • tachypnoea

Shock

  • decreased level of consciousness
  • pale mottled skin
  • cold extremities
  • prolonged CRT
  • weak peripheral pulses
  • hypotension
  • tachypnoea, tachycardia
31
Q

12) What would you need to cover in the hx?

A
  • onset, freq of stools/vomits, duration
  • number of times urinated in past 24 hours
  • risk factors for dehydration (<1 years old, low birth weight, signs of malnutrition, stopped breastfeeding during illness, not tolerating fluids, >5 diarrhoeas or >2 vomits in past 24 hours)
  • other family/contacts unwell?
  • consumption of unsafe foods like takeaway
  • recent foreign travel
  • clinical evidence of dehydration
  • features of hypernatraemia
32
Q

12) How would you manage dehydration?

A

5%

  • assess risk, give education and advice
  • continue Breastfeeding and usual milk feeds
  • encourage usual fluids
  • offer 5ml/kg after each loose stool/vomit

5-10%

  • continue breastfeeding
  • Oral Rehydration Salts 50ml/kg over 4 hours + maintenance
  • consider NG and ondansetron if not tolerated

>10%

  • IV/IO access = fbc, u&es, glucose, abg, cultures
  • IV fluid bolus = 10-20ml/kg of 0.9% NaCl
  • IV Rehydration = 0.9% NaCl + 5% dextrose (+KCl)
33
Q

13) 2 month old presents with choking, apparent apnoea and cyanosis

What is a Brief Resolved Unexplained Event and some differentials?

A

BRUE = a sudden brief (<1min), now resolved episode in an infant with…

  • cyanosis or pallor
  • absent, decreased or irregular breathing
  • marked changes in tone (hypo or hypertonia)
  • altered level of consciousness

Only applies when there is no other explanation after assessment

Other differentials…

  • normal gag/choke/cough with feeds
  • periodic breathing/ resp pauses
  • Infection = resp (RSV, pertussis), sepsis, meningitis, UTI, pneumonia
  • GI = GOR, swallowing dysfunction
  • Neuro = epilepsy, neuromuscular disorders
  • Cvs = central or obstructive apnoea, arrhythmias, CHD, airway abnormalities
  • inborn errors of metabolism
  • child abuse
34
Q

13) How would you manage BRUE based on the risk screening questions?

  • Age >60 days
  • if premature - born at gestational age >32 and currently postconceptional age >45 weeks
  • only 1 BRUE
  • duration of BRUE <1 min
  • no cpr requried by trained medical care providor
A

Risk screening all yes = low risk

  • educate carer, offer CPR training, monitor

No to any risk screening = high risk

  • admit for continuous oximetry observations
  • ECG
  • fbc, abg, glucose, metabolic screen
  • blood and urine culture
  • resp virus testing, pertussis testing
  • observe/evaluate feeding
  • anti-reflux medication
  • home monitoring
35
Q

14) What are some sepsis red flags?

A

Appearance

  • appears ill, mottled/ashen, cyanosis, non-blanching rash

Breathing

  • grunting/ apnoea, spo2 <90%, increased O2 requirement, tachypnoea

Circulation

  • pulse <60bpm, tachycardia

Demeanor

  • drowsy, weak high pitched/continuous cry

Exposure

  • temp <36 or >38.5
36
Q

14) What is the UHL sepsis 6?

A
  • supplementary O2 via rebreathing facemask
    • titrate O2 and aim for spo2 >94%
  • IV/IO access
    • blood culture
    • abg for glucose and lactate
    • fbc, crp, coagulation, u&es
    • LP unless contraindicated
    • consider urine, csf or line culture, meningococcal pcr (do not delay treatment for these)
  • Give IO/IV broad spectrum antibiotics
  • IV fluid resuscitation
    • give 20ml/kg 0.9% NaCl if lactate >2mm/L
  • Escalation
    • inform a senior
    • notify CICU if lactate >4mmol/l or not improving
  • Consider inotropic support if normal physiological parameters are not restored after 40ml/kg fluids
37
Q

15) How would you manage a mild/mod acute asthma exacerbation?

A
  • up to 10 puffs of salbutamol via spacer
  • reassess in 30 mins
  • if no better or worse, give 10 puffs salbutamol ever 20-30 mins
    • repeat up to 3 times
    • reassess each time
  • If still no better then procede onto severe pathway
38
Q

15) How would you manage a severe acute asthma exacerbation?

A
  • call senior help
  • high flow O2
  • salbutamol + ipratropium nebs every 20 mins
  • oral steroid or IV hydrocortisone
  • consider CXR
  • continuous assessment over 30 mins
  • if improved, admit to wards and give O2 to maintain spo2 >92%
    • continue to give salbutamol every 30-60 mins
  • If not improved, proceed onto life threatening pathway
39
Q

15) How would you manage a life threatening acute asthma exacerbation?

A
  • A-E
  • high flow O2
  • salbutamol + ipratropium nebs ever 10-20 mins
  • immediate IV access for IV hydrocortisone
    • take abg, u&es, fbc
  • continuous monitoring and cardiac monitoring
  • if improving, move to wards, give O2 to maintain sats at >92% and give salbutamol every 30-60 mins
  • If not improving…
    • CXR
    • continuous monitoring
    • IV salbutamol bolus
    • Consider IV MgSO4 bolus
    • IV fluids
40
Q

2) What is involved in a septic screen?

A
  • blood cultures
  • urine culture
  • CXR
  • LP
41
Q

2) What are some organisms that cause Meningitis that you need to consider in children

  • Neonates
  • 1 month - 6 years
  • More than 6 years
A

Neonates =

  • Group B Strep
  • E.Coli
  • Listeria

1 month - 6 months =

  • Neisseria Meningitidis
  • Strep Pneumonia
  • Haemophilus Influenzae

> 6 months =

  • Neisseria Meningitidis
  • Strep Pneumonia
42
Q
A
43
Q

2) How would a meningitis typically present?

A
  • poor feeding, irritability, fever, poor urine output
  • high pitched cry, bulging fontanelles, petechial rash
  • Neck stiffness = Brudzinski’s sign
    • causes patients to flex their hips and knees when neck is flexed as neck is so stiff

4th Year (17 decks)

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