The sick child

Question 1

how do HR, BP and resp rate change over time from birth to adulthood?

Answer 1

HR starts off fast (110-160) and decreases ro 60-100
BP starts off low (70-90 systolic) and increases to 110-120 systolic
resp rate starts off fast ((30-40) and decreases to 15-20

Question 2

describe the general anatomical differences in infants

Answer 2

relatively large heads and prominent occiput
sitting height proportionally more
relatively large surface area compared to volume
high anterior larynx/floppy epiglottis
more flexible ribs
blood volume is 80ml/kg
HbF at birth

Question 3

what is the most common causative system in presenting children?

Answer 3

respiratory
- bronchiolitis
- URTI
- croup
etc

Question 4

what is the commonest reason for acute illness in children?

Answer 4

sepsis

Question 5

general treatment outline for sepsis?

Answer 5

supportive

antimicrobial

Question 6

what is bronchiolitis?

Answer 6

acute inflammatory injury of the bronchioles
usually viral (RSV)
supportive treatment

Question 7

clinical signs of bronchiolitis?

Answer 7

widespread fine crackles all around lung fields due to secretions
struggle with feeding
barking cough
starts off with cold (same as adults) and then progresses into chest

Question 8

how is bronchiolitis managed?

Answer 8

usually viral so no real treatment, just supportive
can insert NG tube for feeding if needed
can need CPAP if severe (forces air up nose so that when you breath out, your lungs don’t collapse)

Question 9

what is croup?

Answer 9

laryngotracheobronchitis
usually viral (parainfluenza)
can narrow upper airway

Question 10

signs of croup?

Answer 10

stridor

Question 11

management of croup?

Answer 11

steroid treatment

Question 12

noisy breathing in is caused by an obstruction where?

Answer 12

upper airway

Question 13

noisy breathing out (wheeze) is caused by obstruction where?

Answer 13

lower airway

Question 14

other differentials in croup?

Answer 14

epiglottitis (ENT emergency)
any upper resp tract obstruction
inhaled foreign body

Question 15

how can you differentiate for croup?

Answer 15

had a cold for a couple of days, barking cough

Question 16

causes of a wheeze in children?

Answer 16

not always asthma
episodic wheeze (more likely to get wheezy in cold weather, if they have a cold/virus etc - due to previous bronchiolitis infection)

Question 17

how is asthma/episodic wheeze managed?

Answer 17

in the same way
steroids, bronchodilators, oxygen
(don’t always give steroids in <2 y/o)

Question 18

give 2 CNS presentations in children?

Answer 18

meningitis (bacterial and viral)

encephalitis (commonly viral)

Question 19

how are meningitis/encephalitis symptoms investigated?

Answer 19

lumbar puncture and imaging

Question 20

how are meningitis/encephalitis symptoms managed in infants?

Answer 20

can be difficult to tell in very young if meningitis is the true diagnosis so antibiotics are given regardless

Question 21

signs of encephalitis?

Answer 21

focal neurological deficit

Question 22

signs of meningitis?

Answer 22

non-blanching rash (not always present - only a sign on meningococcal meningitis)
- if rash is present, just treat without lumbar puncture

Question 23

general signs on CNS problem?

Answer 23

febrile seizures
vasovagal episode (fainting)
reflex anoxic seizures (stops breathing after a shock or knock to the head)
breath holding attacks (breath holding while crying, can cause infant to black out, but harmless)
behavioural episodes
epilepsy
arrhythmias
- all of the above can present similarly to seizures

Question 24

how is a first seizure like episode managed?

Answer 24

everyone gets an ECG

don’t treat after the first fit

Question 25

initial approach to management of accidents and trauma in children?

Answer 25

basic life support

Question 26

what is the impact of flexible ribs in children?

Answer 26

means it is difficult to break a child’s ribs - therefore if ribs are broken think NAI

Question 27

other common presentations of NAI?

Answer 27

retinal haemorrhages (from shaking)
rib fractures
bruises in different and odd places
- behind ear
- not on bony prominences

Question 28

what can cause GI obstruction in children?

Answer 28

congenital pyloric stenosis
volvulus
intussusception
malrotation (infants)

Question 29

signs of pyloric stenosis

Answer 29

aklalotic
skinny
vomiting

Question 30

common GI/urogenital presentations in children?

Answer 30

viral gastroenteritis
GI obstruction
acute abdomen (appendicitis)
UTI
testicular torsion

Question 31

common cardiovascular presentations in children?

Answer 31

congenital heart disease (cyanosis, heart failure)
arrhythmias (SVT etc)
bacterial endocarditis (rare)

Question 32

what is the paediatric sepsis 6?

Answer 32

6 things you should do within an hour when a child has sepsis
- high flow oxygen
- IV access and blood tests (blood cultures, glucose and lactate)
- IV or IO antibiotics
if shocked
- consider fluid recuscitation
- consider inotropic support early
- involve senior clinicians/specialists early

Question 33

STOP part of sepsis protocol?

Answer 33

recognition
child with infection + 2 of the following
- temp <36 or >38
- tachycardia
- altered mental state
- reduced peripheral perfusion

Question 34

THINK part of sepsis protocol?

Answer 34

reduce threshold for treatment (some children are at a higher risk so should be treated with fewer signs)

Question 35

what can increase chance of survival after arrest?

Answer 35

if it is caught at respiratory arrest before it becomes a cardiac arrest

Question 36

adult vs child arrest?

Answer 36

adult usually cardio

children usually resp first (then becomes cardio)

Question 37

how is airway (in ABCDE) different in infants to adults?

Answer 37

larynx is higher in infants so don’t do head tilt chin lift as this can compress the airway
just return to neutral position

Question 38

how can you assess effort of breathing?

Answer 38

rate
recession
accessory muscle use
grunting
nasal flaring

Question 39

how can you assess efficacy of breathing?

Answer 39

expansion
additional noises (wheeze, stridor)
pulse oximetry
effects on end organs (conscious level, pallor, tachycardia)

Question 40

how can circulation be assessed?

Answer 40

HR
rhythm
pulse volume
capillary refill
BP
effects on other organs (conscious level, skin perfusion, urine output)

Question 41

jooboobnnoob mcoobwoob?

Answer 41

Joanne McEwan

Question 42

what is a dangerous cardio sign in children and why?

Answer 42

hypotension
children are very good at maintaining blood pressure so if its low there must be a cause
- pre-terminal sign
- need 25+% blood loss before BP control drops

Question 43

how is shock managed (cardio/hypovolaemic shock)?

Answer 43

20ml/kg of 0.9% saline
reassess
repeat if still shocked
may need blood if trauma/haemorrhage
- if >20ml/kg of fluid, may need inotropes but still need more fluid
- at 60ml/kg, PICU should be aware

Question 44

how much blood equates to 25% of circulating volume in children?

Answer 44

20ml/kg

- point at which clinical shock is detected

Question 45

signs of <5% dehydration?

Answer 45

minimal or no clinical signs

Question 46

signs of 5-10% dehydration?

Answer 46

mildly dry mucous membranes
slightly decreased skin turgor
mildly reduced urine output

Question 47

signs of >10% dehydration?

Answer 47

dry, sunken mucous membranes
decreased skin turgor
significantly reduced urine output
shock
altered conscious level

Question 48

how is conscious level assessed?

Answer 48

AVPU
GCS
pupils
posture
don't ever forget glucose

Question 49

how is disability assessed?

Answer 49

conscious level
posture
pupils