Seriously Ill Child

Question 1

A women comes in saying her baby sleeps to much, what are some questions you can ask to know if its pathological?

Answer 1

• Sleep up to 18h / day
• Fix but don’t follow
• Wake regularly for feeds
• Suck strongly on the breast
• Rousable to activity (e.g. limb movements)
• Normal sounding cry
• Flexed posture w. some time - Preterm babies Ø until ~32wks
• May have some chest indrawing (esp. premature)
• May have periodic respiration
• Ø apnoea = period of no respiration that is abnormally long
  
  • serious sign:
    
    • ​RSV (bronchiolitis)
    • Croup
    • Acidosis
    • Sepsis
    • Patent ductus arteriosis

Question 2

What are some system observations to measure to determine wellness of a child?

Answer 2

CNS

• State
• Arousal
• Posture

Resp

• Resp distress
• Hypoxemia
• UAO

CV

• Adequate end-organ perfusion
• Hydration
• HR
• BP

Question 3

A seriously ill child is in ED and you have to start standard resus, what are some considerations you should consider?

Answer 3

• DO NOT INTUBATE - unless the child has been resuscitated with fluid, can cause circulatory collapse.
• start with 20ml/kg
• once you get to 40ml/kg and the child still has signs of shock do something else (vasopressor, ionotrope, ICU)
• Hartmann’s is good in acidosis (lactate converted by bicarb) - vs normal saline which causes high chloride and exacerbates acidosis.

Question 4

Types of Tachypnea on examination?

Answer 4

• expiratory wheeze (long expiratory phase)
  
  • asthmatics
  • bronchiolitis
  • anaphylaxis
• expiratory cough/wheeze (short expiratory phase)
  
  • pneumonia - maintain lung volumes
• inspiratory stridor
  
  • croup
  • foriegn body inhalation
  • anaphylaxis
• Effortless tachypnea
  
  • acidosis (diabetes, sepsis, dehydration, methylene glycol ingestion)

Question 5

What type of rash do you get in GAS disease?

Answer 5

• scarlatinoform red erythematous rash

other rashes not to miss?

• non-blanching petechial rash (rub they don’t go away), <2cm petechial, >2cm purpuric - meningococcal infection

Question 6

What are the types of shock? What are some signs?

Answer 6

Signs:

• Tachycardia
• Increased RR
• pulse (brachial, femoral then carotid)
• capillary refill (push for 5 seconds, <3seconds normal)
• Hypoperfusion - cool peripheries
• Altered concious state
• hypotension is a late sign in kids

Types:

1. neurogenic (loss of sympathetic input, above T6)
2. septic/anaphylaxis (distributive)
   
   • Warm shock
3. obstructive (Cardiac - coarctation, duct dependent)
4. hypovolemic
   
   • Cool shock

Question 7

What is the management of someone who is in shock?

Answer 7

DRS ABCDE

• A - steth out - look and have a listen - not sure assume not breathing
• B - neonatal resus - give O2 and some breaths
• C - circulation - cap refill central, BP, pulse (femoral/brachial - not carotid).
  
  • Bolus - 20mls/kg. 2IV lines.
  • Ionotropes - +/- cardiogenic.
• D - disability
• E - exposure

Question 8

What is a quick way to approximate someones weight based on age in an emergency?

Answer 8

(age+4) x 2

often underestimates in devloped countries, but is quick for approximating.

Question 9

A child with DKA has hyperglycemia, acidemia, hypocapneoa, low bicarb, low sodium and low potassium. Explain the sodium result. Define DKA.

Answer 9

• metabolic acidosis with some compensation
• dehydration would expect it to be higher
  
  • corrected sodium not actual?
  • pseudohyponatremia - dilutional.
    
    • in hyperglycemia and hypercholestrolemia

What is DKA?

1. low pH
2. high glucose
3. presence of ketones

Question 10

What is the Management of someone in DKA? What specifically do you need to monitor?

Answer 10

• fluid bolus:
  
  • on conservative side - 10mls/kg bolus + maintenance (see guideline)
• insulin +/- dextrose (aim for 5-12 range)
  
  • disconnect pump
  • IV access - 2.4units/hr generally.
• Potassium - always give. 40mmol/L KCL. insulin causes intracellular shift.
• NBM
• ECG - baseline and potassium
• Monitor GCS

Question 11

Why is it so important to monitor GCS in a DKA patient?

Answer 11

• Sodium - overcorrected.
• DKA cerebral oedema (one theory). Lower blood sugar in blood than in CSF water flood brain.
  
  • Patients at risk fo cerebral oedema - really sick, younger, concurrent meningitis or resp infections.
  • Monitor for papilloedema, frontanelles, Obs - cushings triad (bradycaridia, hypertensive, mixed RR)
• Ketotic seizures.

Question 12

How do you classify a child’s hydration status?

Answer 12

• Mild - dry membranes, mild tachy, decreased UO
• Moderate - sunken eyes, respiratory rate increase, tachycardia, reduced tissue turgor, lethargy
  
  • delayed CRT >2secs (centrally)
• Severe - shock, mottled limbs, altered consciousness

Question 13

What is Reye’s Syndrome? How does it present?

Answer 13

• a non-inflammatory encephalopathy
• Presentation:
  
  • abrupt vomiting 12hrs-3days after viral illness
  • associated with aspirin
  • neurological Sxs (lethargy, diarrhoea)
• complications:
  
  • brain herniation
  • SiADH
  • ARF
  • sepsis etc…
• 20-50% mortality

Question 14

What are the common organisms that cause meningitis in infants?

Answer 14

• <2mths old:
  
  • GBS
  • E. coli
  • listeria
• >2 mths:
  
  • streptococcus pneumoniae
  • neisseria meningitidis
  • HIB