The sick child Flashcards
What are common symptoms of a sick child?
Difficulty breathing Poor feeding Fever Rash Lethargy Dehydration
What is the normal HR and RR for a child under 1?
HR: 110-160
RR: 30-40
What is the normal HR and RR for a child aged 1-2?
HR: 100-150
RR: 25-35
What is the normal HR and RR for a child aged 2-5?
HR: 95-140
RR: 25-30
What is the normal HR and RR for a child aged 5-12?
HR: 80-120
RR: 20-25
What is the normal HR and RR for a child over 12?
HR: 60-100
RR@ 15-20
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)
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
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
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
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
What can lead to circulatory failure?
Fluid loss: blood loss, gastroenteritis, burns
Fluid maldistribution: septic shock, cardiac disease, anaphylaxis
What can lead to respiratory failure?
Respiratory distress: foreign body, croup, asthma
Respiratory depression: convulsions, raised ICP, poisoning
How is breathing assessed in a child?
Effort of breathing
Efficacy of breathing
How is the effort of breathing assessed?
Rate Recession Accessory muscle use Grunting Nasal flaring
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
How is circulation assessed?
HR Rhythm Volume Cap return BP Effects on other organs HYPOTENSION IS A PRE-TERMINAL SIGNAL
How is circulation managed?
20ml/kg of 0.9% saline then reassess
Repeat is still shocked
At 60ml/kg, inform PICU
How will 5-10% dehydration present?
Mildly dry mucous membranes
Decreased skin turgor
Mildly reduced urine output
Normal conscious level
How will more than 10% dehydration present?
Dry ++ mucous membranes Sunken fontanelle Decreased skin turgor Significantly reduced urine output Shocked Altered conscious level
How is conscious level assessed?
AVPU GCS Pupils Posture - decorticate/ decerebrate DEFG (don't ever forget glucose)
What is assessed in exposure?
Temperature
Rash/ bruising
What is the normal systolic BP for a child under 1?
70-90 mmHg
What is the normal systolic BP for a child aged 1-2?
80-95 mmHg
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
