Spotting the sick child

Question 1

T/F: children’s symptoms are often vague and tend to be quite non-specific

Answer 1

True - such as vomiting or a temperature whatever the cause (physical examination plays a greater part in diagnosis than it does in adults)

Question 2

The 3 minute toolkit can help diagnose an acutely ill child - what does it encompass

Answer 2

A: obstructed? > secretions, foreign body, stridor B: struggling to breathe? > assess RR, look for recession/ accessory muscle use, check O2 sats, auscultate chest C: poor circulation? > assess colour of skin, HR, CRT (sternum + fingers/toes), BP, warm or cold hands/ feet D: neurological state > pupil response to light, limb tone and movement, AVPU/ GCS E: expose and examine top-to-toe > rashes, injury/ trauma, bruises (consider NAI) ENT: ear, nose and throat T: temperature (tympanic or axillary thermometer or rectal if very unwell) T: tummy > soft, distended, tender, BS, masses, hernias. Never forget the testes in boys. Urinalysis

Question 3

A: SECRETIONS/ STRIDOR - check for secretions (e.g. in ____) - if you hear stridor consider what? - T/F: you must examine the throat if you hear stridor - airway opening manoeuvres - like what? - airway adjuncts - like what?

Answer 3

1) bronchiolitis 2) foreign body or coup 3) do NOT examine the throat if you hear stridor - risk that you could cause deterioration. Await senior help 4) Neutral in infant, head tilt chin lift in a child, jaw thrust 5) oro/nasopharyngeal airway (will also check if gag reflex)

Question 4

A: UNPROTECTED AIRWAY When assessing decreased consciousness and you may need an anaesthetists, what is the most useful test you can do?

Answer 4

See if there is a gag reflex - try to insert an oropharyngeal airway and see if there is a reaction > coughing = they are protecting their airway. If not > maintain a jaw thrust and call an anaesthetist

Question 5

normal RR and HR for a neonate?

Answer 5

RR: 30-40 HR: 110-160

Question 6

normal RR and HR for 2-5 year olds?

Answer 6

RR: 25-35 HR: 95-140

Question 7

normal RR and HR for 5-12 year olds?

Answer 7

RR: 20-25 HR: 80-120

Question 8

normal RR and HR for 12-18 year olds?

Answer 8

RR: 15-20 HR: 60-100

Question 9

Visual signs of cyanosis will not be detectable until the situation is very serious, i.e. saturations of what?

Answer 9

85% or less

Question 10

Normal children should have sats of at least (1)%. Levels of less than (2)% imply significant illness. Below (3)% is alarming

Answer 10

1) 96 2) 94 3) 90

Question 11

How to minimise the difficulties associated with auscultating a child’s chest?

Answer 11

• if they’re crying, try to catch the breath sounds as they breathe in - they may settle with a dummy or finger to suck - warm stethoscope if cold - let them play with the stethoscope and turn it into a game

Question 12

T/F: auscultation is of less value than in adults

Answer 12

true, because the chest is small and therefore noises transmit all over the chest. Usually the most information you can get is whether there is wheezing (asthma) or wet crepitations (bronchiolitis)

Question 13

How to assess colour in circulation?

Answer 13

if they’re pale, ask the parents what their normal colour is. Look for mottled arms/ legs - some children are mottled frequently so check with parents. If its unusual this is a sign of poor perfusion

Question 14

How to measure pulse

Answer 14

ensure child is calm (crying can increase HR) measure radial pulse for 30s then x2 In babies <6/12 brachial is more easily felt If in hospital, pulse oximeter or cardiac monitor may give you a more accurate reading

Question 15

How to measure CRT?

Answer 15

pressure for 5 seconds, >2 seconds is abnormal Central refill time (sternum/ forehead) produces less false positive results but peripheral (fingers/ toes/ hands/ feet) may be an earlier sign of decompensation

Question 16

why is CRT a particularly useful measure of circulation in children?

Answer 16

as BP doesn’t drop until the child is extremely ill and tachycardia is not 100% reliable

Question 17

why note temperature of hands and feet?

Answer 17

they will be cooler if there’s peripheral vasoconstriction e.g. sepsis or dehydration

Question 18

T/F: BP is often not worth measuring in children

Answer 18

true - as they can get upset when the cuff tightens around their arm. Unless you’re v worried about circulation (e.g. drowsy/ very sick appearing child).

Question 19

T/F: dropping BP is often one of the first clinical signs of shock in a child

Answer 19

false - BP is maintained until very late in shock cause kids have such good peripheral vasoconstriction to compensate

Question 20

what size of cuff should be used when measuring BP?

Answer 20

2/3 of the length of the upper arm. May be easier to take from the high if infant is struggling

Question 21

when might sluggish pupillary responses be seen?

Answer 21

after a fit or drug overdose

Question 22

changing pupil sizes may be a sign of?

Answer 22

ongoing seizures, even if there are not tonic-clonic movements. abnormal gaze may also be seen after a seizure

Question 23

asymmetry of the pupils implies what?

Answer 23

a SOL within the brain e.g. an extradural or subdural haemorrhage from a head injury

Question 24

Comparison of the tone and movements of the limbs is important if you’re worried about what

Answer 24

a SOL in the brain, such as a haematoma from a head injury or a tumour causing seizures If you pick up a difference between right and left which hasn’t been previously noted, the child is likely to need a CT brain scan. These signs are only likely if a patient is not alert and orientated

Question 25

Most important part of the Disability section?

Answer 25

observe the child’s behaviour - alert? (AVPU). Also irritability/ drowsiness and whether they are just upset or inconsolable

Question 26

True irritability may indicate what? (i.e. child can’t be consoled)

Answer 26

raised ICP or meningitis

Question 27

when is drowsiness common in children?

Answer 27

common after a fit also common when they have a high temperature

Question 28

important points about ENT exam

Answer 28

• needed in any child with a fever - best left to the end in case the child gets upset - ensure the parent/ assistant holds the child still

Question 29

T/F: pink eardrums are often an indication of infection in a child

Answer 29

false - their eardrums re often pink, just because of the temperature

Question 30

T/F: large, red tonsils are pathognomonic of tonsilitis

Answer 30

false - large and a bit red is normal (the temp is high and they have an increased blood supply) In true tonsillitis, the tonsils are large with an exudate

Question 31

what method of recording temperature is recommended in small babies?

Answer 31

axillary temperature (ears too small for a tympanic thermometer)

Question 32

how to examine the abdo in kids

Answer 32

best lying flat on a trolley (if child is very upset can do on parents lap). Firstly feel around the abdomen gently, enquiring where it hurts. Once they’re relaxed you can feel deeper for tenderness, peritonism or masses.

Question 33

What is the BM Stix?

Answer 33

the equipment used for testing blood glucose NB: not usually needed in a child who’s alert and orientated

Question 34

T/F: a low blood sugar, or hypoglycaemia, occurs in children quite easily in children

Answer 34

true - if they have had a low calorie intake for a day or 2, have ingested alcohol, have severe sepsis or have a congenital metabolic abnormality

Question 35

Normal range for blood glucose in a child?

Answer 35

3-5 millimoles per litre

Question 36

most common reason for a young child to be taken to the doctor?

Answer 36

Difficulty in breathing or cough - often triggered by infection (viral most common)

Question 37

the most common organisms causing respiratory problems in kids?

Answer 37

Strep pneumoniae, Haemophilus influenzae, Pertussis, Mycoplasma, and the influenza viruses

Question 38

most common causes of breathlessness in kids?

Answer 38

asthma, bronchiolitis, pneumonia, and croup.

Question 39

what causes asthma

Answer 39

hyper-reactive airways > bronchi constrict and secrete mucus > narrowed airways produce a wheeze

Question 40

what is a wheeze

Answer 40

high pitched expiratory sound

Question 41

T/F: the inspiration phase tends to be prolonged in asthmatics

Answer 41

false - the expiration phase

Question 42

Under the age of __, children do not have typical asthma, and beta agonists tend to be less effective.

Answer 42

one little you can do - except admit the child if they’re not feeding or require oxygen

Question 43

what is croup.

Answer 43

viral infection of the upper airway (most often parainfluenza virus) Commonest in toddlers, makes them miserable

Question 44

characteristic symptoms of croup?

Answer 44

Airway inflammation > hoarse voice and barking cough Turbulent airflow through the narrowed airway > stridor (inspiratory or expiratory) Other signs of upper airway obstruction > intercostal recession, subcostal recession, sternal recession and tracheal tug

Question 45

Croups responds well to what medication? What about severe croup?

Answer 45

Steroids - such as oral dexamethasone, predisolone or nebulised budesonide. Severe - adrenaline nebuliser can be used for a more immediate effect while waiting for steroids to kick in (5 mls of 1:1000 adrenaline into a nebuliser, and you should see an improvement over 20 minutes or so) - may need to be repeated

Question 46

bronchiolitis age group?

Answer 46

mainly 1 month - 1 year olds

Question 47

symptoms of bronchiolitis?

Answer 47

infects the lower airways causing secretions > shortness of breath, wheezing, a wheezy/ wet sounding cough, a runny nose - and sometimes a mild temperature (less than 38)

Question 48

main causative virus of bronchiolitis?

Answer 48

RSV

Question 49

treatment for bronchiolitis?

Answer 49

no specific treatment but if they are not feeding, have significant respiratory distress, or are hypoxic, they need to be admitted to hospital for oxygen and fluids

Question 50

In children under 3 years old with signs of sepsis, what investigations is usually performed in children and why?

Answer 50

a chest X-ray to detect pneumonia, because the clinical signs are notoriously subtle

Question 51

what subtle signs of a pneumonia may be noticed?

Answer 51

general signs of severe infection (using 3 minute toolkit) e.g. lethargy, fever and a high heart rate, particularly if out of proportion to the degree of fever. In bacterial pneumonia they will appear more unwell and lethargic than with common viral respiratory infections, with a temperature typically above 38.5 degrees centigrade, and they often refuse food and drink NB: compared with adults, cough is a less reliable symptom (sometimes there is no cough). Chest auscultation is also less reliable (small so transmits sounds all over - focal signs hard to detect)

Question 52

When examining the respiratory system what is the most important discriminating sign for a pneumonia?

Answer 52

a raised respiratory rate - in kids < 3, a raised respiratory rate is sufficient to warrant a CXR low oxygen sats are another imp clue

Question 53

T/F: the smaller the child the easier and quicker they can go into respiratory failure

Answer 53

true - babies under 3 months are particularly vulnerable to hypoxia and apnoeas Hx of apnoea is a red flag. Any baby who has had an apnoea needs to be admitted to hospital urgently.

Question 54

what is an important aspect to cover in the history of any child with a respiratory illness

Answer 54

whether they were born prematurely - if they required care on the Neonatal Unit you should have a low threshold for admission to hospital (Can deteriorate quickly) Same for any babies with cardiac or respiratory diseases Healthy small infants often have noisy breathing simply because the airways are so small. If the parents say the baby has always been like this you don’t need to worry (most grow out of it by 6 months of age).

Question 55

If an infant has bronchiolitis, the diagnosis is usually fairly obvious, unless the baby is only a few weeks old, in which case it may present with an ____

Answer 55

apnoea In most cases there is a snuffly nose, noisy breathing, wheezing and a wet cough.

Question 56

Admission to hospital will be determined by what factors for respiratory illness?

Answer 56

whether the infant is feeding, is tiring, or needs supplemental oxygen.

Question 57

T/F: Infants who have had bronchiolitis in the past often go on to get a recurrent cough and wheeze for a year or so.

Answer 57

true - usually triggered by viral upper respiratory tract infection. The coughing and wheezing usually starts a couple of days after the runny nose, and tends not to respond to standard asthma treatment so is usually described as post-viral wheeze rather than asthma.

Question 58

when would a wheeze caused by previous bronchiolitis be able to be differentiated from asthma?

Answer 58

>2 years old they usually grow out of the wheezing associated with bronchiolitis as a baby. Those with FH of asthma, or who are atopic (hayfever/ ezcema) are more likely to have recurrent wheezing episodes, which we would call asthma.

Question 59

Key points in the history when assessing acutely wheezy children?

Answer 59

assess activity level, eating and drinking, ability to sleep without disturbance and how ill they have become in the past, esp if they’ve needed to be admitted to ICU/ needed several courses of steroids in the past

Question 60

things to look for when considering how unwell a child with difficulty breathing is

Answer 60

level of alertness and how interested they are in their surroundings, their posture and their ability to speak

Question 61

A runny nose is described as ____ in medical terms, and this is a feature of (which condition).

Answer 61

coryza bronchiolitis

Question 62

wheezing is a noise from the lower airways which may occur due because they are constricted, in ____, or full of secretions, as in _____.

Answer 62

asthma bronchiolitis

Question 63

what is ‘grunting’ in a child with respiratory distress?

Answer 63

when infants close their glottis to generate end expiratory pressure, to keep their alveoli open when they have lots of secretions. Seen in bronchiolitis. Is a sign of significant respiratory distress. Crying in a strained fashion, with prolonged expiration, does a similar thing.

Question 64

how is the expiration phase affected in children with In children with bronchoconstriction?

Answer 64

prolonged e.g. asthma or bronchiolitis

Question 65

signs of increased work of breathing?

Answer 65

recession of the ribs, and the use of accessory muscles (amerians use the term ‘retractions’)

Question 66

name the different types of recession

Answer 66

tracheal tug, supraclavicular recession, sternal recession, intercostal and subcostal recession (work from top to bottom to remember all) Categorised as mild, moderate or severe

Question 67

T/F: an older child has to be in a greater degree of respiratory distress for you to see recession

Answer 67

true (chest wall less soft) and vice versa, recession i v common on neonatal unit, even when the baby isn’t that unwell

Question 68

what kind of recession indicates more severe respiratory distress?

Answer 68

sternal - because the sternum is a large bone, and to draw it in means that severe effort is being put in sternal recession and tracheal tug are quite prominent in kids with upper airway obstruction such as croup

Question 69

what signs of accessory muscle use may be seen in respiratory distress

Answer 69

Abdominal breathing (forced diaphragm movement) Head bobbping (pulling on the sternomastoid muscles in the neck) Nasal flaring can also be seen

Question 70

why are O2 sats so important to measure in a child?

Answer 70

naked eye wont detect cyanosis until the patient is seriously ill. In children, obvious cyanosis in a normally healthy child implies a life threatening condition You can see that once oxygen saturations reach 90% or so, there is a rapid deterioration in the patient’s oxygen levels with each stage of decompensation after that point.

Question 71

sats in normal healthy children?

Answer 71

98-100%

Question 72

Supplemental oxygen should be given if the saturations are below what?

Answer 72

95%

With oxygen, saturations should pick up to 100% rapidly. If they remain low despite high flow oxygen, the child is very hypoxic and unwell.

Question 73

when would bronchial breathing be heard in a child

Answer 73

happens when there is a pneumonia with consolidation of the lung, which creates a harsh, blowing, kind of noise in the area just above the consolidation

Question 74

how to tell if a foreign body is stuck in the airway or oesophagus?

Answer 74

Airway: most have been coughed up, brought up by someone doing a Heimlich type maneuvre, or it is small enough to have gone down one of the 2 bronchi, and cause wheezing or a chest infection rather than persistent choking. If truly stuck in the larynx > hypoxic > apnoeic > unconscious/ in cardiac arrest by the time a health professional is present.

Oesophagus: much more common. They’re able to talk/ cry

Question 75

Emergency management of a foreign body stuck in the larnyx and threatening the child’s life?

Answer 75

• bang on the back. Child upsidedown on knee for younger kids, chest thrusts for under 4s, Heimlich for over 4s.
• If these fail, call a senior anaesthetist and an ENT surgeon and try to leave the child alone. Can be given a short acting, inhaled, anaesthetic and the foreign body removed with Magill’s forceps.
• Lost consciousness: use a laryngoscope and retrieve the foreign body with Magill’s forceps without wating for futher help. If difficult to retreive, cricothyrotomy may be needed

Question 76

Appearance and management of a child who has ingested a foreign body? (i.e. stuck in oesophagus)

Answer 76

uncomforable, drooling (hard to swallow), but not hypoxic or showing signs of respiratory distress

Is not immediately life threatening and you can refer the child to the anaesthetic and surgical teams for further management

Question 77

How may a child present if the object goes down the left or right main bronchus?

Answer 77

• will present with wheezing or a chest infection, sometimes months after the event.
• if in the acute phase, listen for for localised wheezing and get a CXR which may show a ball-valve effect where air gets in past the foreign body, but can’t escape as the child breathes out, and the lung becomes progressively hyperinflated. The child will need to be referrred for bronchoscopy to retreive the object.
• (commonly peanuts or beads)

Question 78

what is Apnoea?

Answer 78

a word used to describe a pause in breathing, or stopping breathing

Question 79

T/F: Any infant who has had an apnoea should be referred to hospital by ambulance

Answer 79

true dat

Question 80

Why might a child have an apnoea?

Answer 80

• Infants (esp 1-4 months) may have apnoeas as a sign of illness, not necessarily respiratory in origin
• can happen in various conditions such as bronchiolitis, whooping cough (which is due to Pertussis infection), sepsis, meningitis and fits

Question 81

How to recognise apnoea from a history?

Answer 81

Can be hard to diagnose - should be regarded as having happened during any event which includes floppiness or cyanosis

These symptoms are called an apparent life-threatening event, as this is what it felt like to the parent

Question 82

How does the presentation of whooping cough differ in young babies (i.e. a few weeks old) c.f. older children?

Answer 82

• young babies: tends to present with apnoeas
• It is only in older children that Pertussis causes coughing bouts followed by a big intake of breath which sounds like a whoop

Question 83

What is Status asthmaticus?

Answer 83

acute severe asthma attack, which dodesn’t respond to the normal treatment of 2 or 3 nebulizers or repeated doses of an inhaler.

When an asthma attack is severe and prolonged, children can become very tired and go into respiratory failure and require intubation and ventilation to take over the work of breathing.