The Seriously Unwell Child

Question 1

What are the two main ways a child might present with sepsis?

Answer 1

• Warm - wide pulse pressure and rapid capillary refill
• Cold - narrow pulse pressure and slow capillary refill
• Other features: tachycardia, fever OR hypothermia, tachypnoea, altered conscious state

Question 2

What is the adrenaline dose required for an acute anaphylactic reaction?

Answer 2

• 0.01 mg/kg of 1/1000. Repeat after 5 minutes if no improvement

Question 3

What are the criteria for DKA?

Answer 3

• Hyperglycaemia >11.1 mmol/L
• Metabolic acidosis: venous pH < 7.3 or HCO3- < 15 mmol/L
• Ketonaemia >0.6 mmol/L or ketonuria

Question 4

How would you manage a child in DKA?

Answer 4

• ABCDE, ensure ECG to monitor for early hypokalaemia
• Fluid replacement (RCH guidelines)
• K+ replacement based on initial level (defer if high)
• Insulin (to RCH guidelines)

Question 5

What ongoing monitoring wuld a child in DKA warrant after treatment had been initiated?

Answer 5

• Fluid balance
• Hourly HR, BP, RR, GCS, neuro obs
• Hourly BGL and ketones while on insulin
• VBG and lab glucose, UEC 2 hourly for first 6 hours
• Monitor for cerebral oedema - act early if suspected (mannitol)

Question 6

What is the definition of hypoglycaemia?

Answer 6

• BGL < 2.6 mmol/L

Question 7

What are the contraindications to lumbar puncture in a child suspected of meningitis?

Answer 7

• Contraindications: will give antibiotics anyway, signs of raised ICP, shock, recent seizures, meningococcal septicaemia suspected (e.g. rash), coagulopathy

Question 8

What are some signs of meningitis in a child? What is the main differentiator for encephalitis?

Answer 8

• Full fontanelle (infants), neck stiffness (not in very young), purpuric rash, Kernig’s + (hip flexion with knee extension causes pain)
• Encephalitis - altered conscious state

Question 9

What empiric antibiotics does a child with menigitis require?

Answer 9

• < 2 months: cefotaxime 50 mg/kg and benzylpenicillin 60 mg/kg
• > 2 months: ceftriaxone 50 mg/kg and dexamethasone 0.15 mg/kg

Question 10

What ongoing care does a child being reated for meningitis require?

Answer 10

• Neuro obs, electrolytes and glucose, analgesia
• Continuing antibiotics depending on organism
• Notification to DHS
• Chemoprophylaxis to contacts depending on organism
• Formal audiology assessment within 6-8 weeks (or sooner)