The sick child Flashcards by Joanna Mitchell

What are common symptoms of a sick child?

Difficulty breathing
Poor feeding
Fever
Rash
Lethargy
Dehydration

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What is the normal HR and RR for a child under 1?

HR: 110-160
RR: 30-40

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What is the normal HR and RR for a child aged 1-2?

HR: 100-150
RR: 25-35

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What is the normal HR and RR for a child aged 2-5?

HR: 95-140
RR: 25-30

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What is the normal HR and RR for a child aged 5-12?

HR: 80-120
RR: 20-25

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What is the normal HR and RR for a child over 12?

HR: 60-100

RR@ 15-20

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What are the guidelines for suspecting sepsis in a child?

A child with suspected or proven infection AND at least 2 of the following:
Core temp below 36 or above 38
Inappropriate tachycardia
Altered mental state (sleepiness/irritability/lethargy/floppiness)
Reduced peripheral perfusion (cap refill above 2 secs/ cool or mottled peripheries)

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What factors reduce the threshold in children to think about sepsis?

Infants under 3 mnths
Immunosuppressed
Recent surgery
Indwelling devices/ lines
Complex neurodisability 
High index of clinical suspicion (tachypnoea, rash, leg pain, biphasic illness, poor feeding) 
Significant parental concern

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What is the paediatric sepsis 6?

Give high flow oxygen
Obtain IV or IO access and take blood tests:
Blood cultures, blood glucose, blood lactate
Give IV/IO broad spectrum antibiotics
Consider fluid resuscitation
Consider inotropic support early
Involve senior clinicians

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What is the fluid management in children?

Titrate 20 ml/kg isotonic fluid over 5-10 mins and repeat if necessary
Aim to reverse shock: normal HR, BP and peripheral perfusion
Assess for fluid overload after more than 40 ml/kg

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What inotropic support should be given to children in sepsis 6?

Adrenaline 0.3mg/kg in 50mls 5% dextrose

Commence 1 ml/hr = 0.1mic/kg/min

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What can lead to circulatory failure?

Fluid loss: blood loss, gastroenteritis, burns

Fluid maldistribution: septic shock, cardiac disease, anaphylaxis

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What can lead to respiratory failure?

Respiratory distress: foreign body, croup, asthma

Respiratory depression: convulsions, raised ICP, poisoning

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How is breathing assessed in a child?

Effort of breathing

Efficacy of breathing

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How is the effort of breathing assessed?

Rate
Recession 
Accessory muscle use
Grunting 
Nasal flaring

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How is the efficacy of breathing assessed?

Expansion
Additional noises: inspiratory stridor or expiratory wheeze
Pulse oximetry
Effects on end organs - conscious level, pallor, tachycardia

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How is circulation assessed?

HR
Rhythm
Volume
Cap return 
BP 
Effects on other organs
HYPOTENSION IS A PRE-TERMINAL SIGNAL

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How is circulation managed?

20ml/kg of 0.9% saline then reassess
Repeat is still shocked
At 60ml/kg, inform PICU

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How will 5-10% dehydration present?

Mildly dry mucous membranes
Decreased skin turgor
Mildly reduced urine output
Normal conscious level

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How will more than 10% dehydration present?

Dry ++ mucous membranes
Sunken fontanelle
Decreased skin turgor
Significantly reduced urine output 
Shocked
Altered conscious level

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How is conscious level assessed?

AVPU
GCS
Pupils
Posture - decorticate/ decerebrate
DEFG (don't ever forget glucose)

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What is assessed in exposure?

Temperature

Rash/ bruising

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What is the normal systolic BP for a child under 1?

70-90 mmHg

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What is the normal systolic BP for a child aged 1-2?

80-95 mmHg

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What is the normal systolic BP for a child aged 2-5?

80-100 mmHg

What is the normal systolic BP for a child aged 5-12?

90-110 mmHg

What is the normal systolic BP for a child aged over 12?

100-120 mmHg

What is different in the anatomy of children?

``` Large head with prominent occiput Sitting height proportionally more Large surface area compared to volume High anterior larynx/ floppy epiglottis Flexible ribs Blood volume 80mls/kg HbF at birth ```

How does a large surface area compared to volume impact clinically?

To burns - will lose more volume from a burn

How will a high anterior larynx/ floppy epiglottis impact clinically?

When intubating, need to use a straight bladed laryngoscope as the epiglottis needs to be physically lifted up and out of the way

How does flexible ribs impact clinically?

NAI

What system will the majority of children present with?

Respiratory

What is bronchiolitis, what causes it and how is it treated?

Acute inflammatory injury of the bronchioles Caused by RSV virus most commonly Widespread crackles throughout all lung fields Supportive treatment - smaller feeds or NG tube, oxygen support

What is croup, what causes it and how is it treated?

Laryngotracheobronchitis - narrowing of the upper airways Presents with stridor - barking cough Steroid treatment

What CNS problems to children commonly present with?

Meningitis - meningococcal, strep meningitis, e.coli. Do lumbar puncture and start on antibiotics Encephalitis - commonly coxsackie. Give acyclovir and do a lumbar puncture

What rash will meningococcemia present with?

Fulminant purpura that is non-blanching

What things present as a fit?

``` Febrile seizure Vasovagal episode Reflex anoxic seizure Breath holding attacks Behavioural episodes Epilepsy Arrhythmias ```

What sort of traumas do children present with?

``` RTA Trampoline Burns Ingestion Drowning Choking ALWAYS CONSIDER NAI ```

What GI/urogenital problems do children present with?

``` Viral gastroenteritis GI obstruction - pyloric stenosis, volvulus, intussusception and malrotation Acute abdomen - appendicitis UTI Testicular torsion ```

What CVS problems do children present with?

Congenital heart disease - cyanosis, heart failure Arrhythmias: SVT Bacterial endocarditis

What questions in a history are important for determining the severity of the illness?

``` History of symptoms Red flags Eating/drinking Bowels/urine Parental concern PMH Meds/allergies Family history Immunisation history ```

What will neonates present to the GP with?

Jaundice - UTI/hypothyroidism/galactosaemia/breast milk jaundice/ biliary atresia Vomiting - reflux/CMP intolerance/ pyloric stenosis/ duodenal atresia Failure to thrive Sepsis

What is defined as prolonged jaundice?

14 days in a term infant | 21 days in a preterm infant

What is the buzzword for pyloric stenosis?

Projectile vomiting

What sign in neonates will send them straight to a+e?

Temp of 38 or above

What are common respiratory paediatric presentations?

``` Bronchiolitis - RSV Croup - parainfluenza, influenza, RSV Viral URTI Asthma Acute tonsilitis ```

What are rare respiratory paediatric presentations?

``` CF Acute epiglottitis - immunize against Hib so rare now Foreign body Pneumonia Cardiac causes Malignancy ```

How is the resp system assessed in GP practice?

``` Cyanosis Tachypnea (RR) Wheeze/stridor/ cough Pulse ox Percussion Auscultation ENT exam ```

What GI problems will children present to the GP with?

``` Abdo pain Vomiting Diarrhoea Nausea Constipation ```

From birth to 18 years, what are the common medical causes of abdominal pain?

Gastroenteritis UTI Constipation

From birth to 1 year, what are the common surgical causes of abdominal pain?

Intussusception Volvulus Incarcerated hernia

From 2-5 years, what are the common surgical abdomen presentations?

Intussusception Volvulus Appendicitis

From 6-11 years, what are the common surgical abdomen presentations?

Appendicitis Trauma Testicular torsion

From 12-18, what are the common surgical abdomen presentations?

Appendicitis Trauma Ovarian torsion Testicular torsion

From birth to 1 year, what are the other causes of abdominal pain?

Infantile colic | Hirschprung's disease

From 2-5 years, what are the other causes of abdominal pain?

Mesenteric lymphadenitis HSP DKA Sickle cell

From 6-11 years, what are the other causes of abdominal pain?

``` Mesenteric lymphadenitis Abdominal migraine HSP DKA Sickle cell Pneumonia Functional abdominal pain ```

From 12-18 years, what are the other causes of abdominal pain?

``` Dysmenorrhoea DKA Mittelschmerz (ovulation) Threatened miscarriage Ectopic pregnancy PID IBD Adrenal crisis ```

What are common MSK presentations in children?

``` Inflammatory arthritis Perthes SUFE Osgood Slatters Growing pains Bone tumours Septic arthrits ```

What should you suspect in a child with a limp?

DDH | Perthes

What causes slapped cheek (erythema infectiosum)?

Parovirus B19

What causes molluscum?

Pox virus

What causes scarlet fever?

Streptococcus - triad of florid rash on trunk, rash on cheeks and strawberry tongue

What causes hand foot and mouth disease?

Coxsackie

What childhood development screening is available?

GP 6-8 week check Red light reflex - congenital retinoblastoma Hips - barlow/ortolani Genitalia - undescended testes Femoral pulses - absent in aortic coarctation