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APLS > Structured approach to paediatric emergencies > Flashcards

Structured approach to paediatric emergencies Flashcards

1
Q

What is the structured approach to paediatric emergencies?

A
  1. PREPARE for child’s arrival
    - get help / gather team - work out drug, fluid & equipment needs
  2. PRIMARY assessment/ survey (Immediate):
    - Responsive? (including AVPU)
    - NO: cardiac arrest Mx
    - YES: ABCDE looking for life threatening issues
  3. RESUSCITATION
  4. SECONDARY assessment/ survey looking for key features /clues to likeliest working diagnosis (Focused)
  • focused history (incl. immunisations, drug allergies, development, FHx)
  • clinical examination
  • specific Ix
  1. EMERGENCY Tx
  2. REASSESS focusing on system control (Detailed review)
  3. STABILISATION
  4. TRANSFER to definitive care environment
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2
Q

What is triage?

A

The process by which each child presenting with a potentially serious illness or injury is assigned a clinical priority.

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3
Q

Describe the national triage scale.

A

1/ RED = IMMEDIATE, MAX TIME TO CLINICIAN 0 MINS

2/ ORANGE = VERY URGENT, MAX TIME 10 MINS

3/ YELLOW = URGENT, MAX TIME 1 HOUR

4/ GREEN = STANDARD, MAX TIME 4 HOURS

5/ BLUE = NON-URGENT, N/A

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4
Q

Describe the triage method developed by the Manchester Triage Group.

A
  1. Identify the problem (brief and focused history - child, carers, healthcare professionals)
  2. Gather and analyse information related to the solution (General and specific discriminators help to allocate patients to 1 of the 5 clinical priorities)
  3. Evaluate all alternatives and select one for implementation
  4. Implement the selected alternative i.e. pathway of care begins determined by clinical priority
  5. Monitor the implementation and evaluate outcomes (Process of triage needs to be dynamic, not static, as triage category of the child may change as they deteriorate or get better)
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5
Q

Name and describe 5 general discriminators.

A

The Child Had Little Pain.

  1. Temperature
    - Very Urgent (2) = infant > 38.5 or child < 32
    - Urgent (3) = child > 38.5
  2. Conscious level
    - Immediate (1) = unresponsive
    - Very Urgent (2) = V or P on AVPU
    - Urgent (3) = History of unconsciousness
  3. Haemorrhage
    - Immediate (1) = catastrophic haemorrhage e.g. post trauma
    - V. Urgent (2) = haemorrhage not rapidly controlled by the application of sustained pressure; continues to bleed heavily/ soak through large dressings quickly
  4. Life threat
    - Immediate (1) = any cessation or threat to ABC functions e.g.

A - insecure airway, inspiratory or expiratory stridor

B - absent or inadequate breathing

C - shock

  1. Pain
    - V. Urgent (2) = severe pain
    - Urgent (3) = moderate pain
    - Standard (4) = any lesser degree of pain
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6
Q

How can inadequate analgesia be detrimental to the management of a critically ill child?

A

Pain causes bronchoconstriction and increases in pulmonary vascular resistance leading to hypoxia.

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7
Q

How do you recognise that a child is in pain?

A
  1. Ask the child
  2. Behaviour: crying, guarding, facial grimacing, pallor 3. Physiology: tachypnoea, tachycardia
  3. Anticipate pain due to event e.g. fracture, burn, trauma
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8
Q

Describe the two main types of pain assessment tools.

A
  1. Observation- based pain scores e.g. Alder Hey Triage Pain Score
  2. Self-assessment tools e.g. faces scale or pain ladder (Prior to the painful event e.g. surgery)
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9
Q

Describe the Alder Hey Pain Triage Score.

A
  • 3 different scores for pain: 0, 1 and 2.
  • Assess responses in terms of:
    • cry/ voice
    • facial expression
    • colour
    • posture
    • movement
  • Pain score 0
    • no cry/ complaint/ normal conversation
    • rest normal
  • Pain score 1
    • consolable/ not talking negative
    • short grimace < 50% of thr time
    • pale
    • touching/ rubbing/ sparing
    • reduced movement or restless
  • Pain score 2
    • inconsolable/ complaining of pain
    • long grimace > 50% of the time
    • very pale/ green
    • defensive/ tense posture
    • immobile or thrashing
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10
Q

What are the components of pain management?

A
  1. Environment
  2. Preparation (explanation of procedure and pain relief, play therapist)
  3. Physical (supportive and distractive techniques e.g. parental presence, videos, bubbles, games, transitional objects - blanket/ soft toy)
  4. Pharmacological
  • Local
    • topical e.g. ametop, EMLA, ethyl chloride spray
    • infiltrated e.g. lidocaine (lignocaine), bupivacaine
  • Non opioid e.g. paracetamol, NSAIDs
  • Opiates e.g. morphine, intranasal diamorphine/ fentanyl
  • Inhalational e.g. entonox (nitrous oxide)
  • Sedatives e.g. midazolam, ketamine
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11
Q

How long do ametop, EMLA and ethyl chloride take to work?

A
  • Ametop: 30-45 mins
  • EMLA: 60 mins
  • Ethyl chloride: immediate
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12
Q

What are the side effects of ametop gel?

A
  • erythema
  • itching
  • oedema
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13
Q

How long does the effect of ametop and EMLA cream last?

A

4-6 hours

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14
Q

How old does the child have to be to use ametop gel?

A

At least 1 month old.

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15
Q

Name some common side effects of NSAIDs.

A
  1. gastric irritation
  2. bronchospasm (ask about asthma)
  3. renal impairment
  4. platelet disorders
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16
Q

What are the side effects of morphine?

A
  1. N&V
  2. respiratory depression
  3. peripheral vasodilatation and venous pooling => hypotension
17
Q

Name an opiate antagonist.

A

Naloxone

18
Q

What dose of IV morphine should be given to children in severe pain e.g. major trauma, femoral fracture, significant burns, displaced/ comminuted fractures?

What monitoring is needed?

A

0.1 - 0.2 mg/ kg, infused over 2-3 mins

A further dose can be given after 5-10 mins if necessary.

Monitor the sats and ECG.

19
Q

Is use of morphine contraindicated in head injury?

A

No, if the patient is conscious morphine can be given.

If the consciousness level deteriorates, assess ABC and reverse with naloxone if necessary to determine if secondary to HI or morphine.

20
Q

What are the benefits to using adequate pain relief in HI (including the use of morphine)?

A

Stops the physiological response to pain which may cause increased ICP.

21
Q

What is an appropriate way to titrate IV morphine for a child in pain?

A

TITRATING IV MORPHINE

PAIN IN CHILDREN

2 mg BOLUS

THEN

0.5 mg increments after assessing every 10 mins

NB morphine takes 10 mins to act

APLS (25 decks)

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