Paediatric Emergencies Flashcards

1
Q

Systemic inflammatory response syndrome (SIRS) criteria

A

Generalised inflam response, defined by presence of ≥2 criteria including either abnormal temp or WCC as one:

Abnormal core temp (<36, >38.5)
Abnormal HR (>2.5 SD above normal rate or less than 10th centile for child <1)
Raised RR (>2.5SD above normal for age or mechanical ventilation for acute lung disease)
Abnormal WCC in circulating blood (above or below normal range or >10% immature cells)
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2
Q

Paeds BLS, neonatal resus

A
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3
Q

Sepsis, severe sepsis and septic shock

A

Sepsis - SIRS in the presence of infection
Severe sepsis - sepsis in the presence of CV dysfunction, resp distress syndrome or dysfunction ≥2 organs
Septic shock - sepsis with CV dysfunction persisting after at least 40ml/kg fluid resus in one hour

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4
Q

Common causative organisms of sepsis

A

GBC and E.coli, Listeria monocytogenes - early onset neonatal sepsis
Coagulase-negative staphyloccocus (CoNS) (e.g. staph epidermidis - late onset neonatal sepsis
Others: staph aureus (coagusate +ve), strep pneumoniae, non-pyogenic strep, Neisseria meningitidis

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5
Q

Investigations and management

A

Investigations: clinical suspicion diagnosis and blood; may also be neonatal sepsis RFs - PROM/PPROM, chorioamnionitis (fever duing labour)

Management:
Peads sepsis 6 within 1 hr, transfer to acute setting
IV access - if failed after 2 attempts, gain IO access
LP if: <1m old, 1-3m who appear unwell, 1-3m with WCC <5 or >15x10^9/L
IV fluid resus + 20ml/kg 0.9% NaCl bolus over 5-10 mins
Bloods - clotting ( can be DIC in sepsis), culture, CRP (may take 12-24 hrs to rise), VBG (including glucose and lactate), FBC, U&E+creatinine
CXR, urine dip on MSU

Abx within 1 hr
If meningococcal sepsis -IM benzylpenicillin (community) or IV cefotaxime (in hosp)
Other early onset <72 hrs - GBS, L. monocyto, E.coli - IV cerotaxime+amikacin+ampicillin
Other late onset >72 hrs - CoNS (s. epidermidis) - IV meropenem+amikacin+ampicillin

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6
Q

Signs and symptoms of meningitis

A

Bulging fontanelle, hyperextension of neck and back (opisthotonos)
Headache, photophobia, neck stiffness, fever
- Kernig’s sign - pain on leg straightening
- Brudzinski’s sign - supine neck flexion -> knee/hip flexion
Lethargy, drowsiness, non-blanching rash

HR starts high to compensate ischaemia in brain, then drops as baroreceptos in heart sense high BP

Raised ICP symptoms (late signs) - Cushings triad: high BP, low HR, irregular RR

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7
Q

Investigations for suspected meningitis

A

LP (unless concerned about raised ICP, in which case do CT first)
Blood culture
FBC, CRP, U&E and glucose
Coagulation profile
Further immuno analysis (complement deficiency) if >1ep

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8
Q

Management of bacterial meningitis; child >3m

A

Admit, sepsis 6

Abx

  • <3m: IV cefotaxime + IV amoxicillin/ampicillin
  • > 3m: IM benzylpenicillin stat (if allergy - moxifloxacin&vancomycin) + IV ceftriaxone. Haem influ type b - 10 days; strep pneu - 14 days; neis menin - 7 days

Steroids (dexamethasone) IF CSF shows:

  • Purulent CSF
  • WBC >1000/uL
  • Raised CSF WCC + protein >1g/L
  • Bacteria gram stain
  • > 1m old and H. influ
  • NOT MENINGOCOCCAL

Mannitol to reduce ICP

IV saline sodium chloride 0.9% 4-2-1 maintenance

Follow up: hearing loss audiological assessment, neuro/development problems, renal failure, orthopaedic, skin, psychosocial, renal

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9
Q

Management of bacterial meningitis; child >3m

A

Admit, sepsis 6

Abx

  • <3m: IV cefotaxime + IV amoxicillin/ampicillin
  • > 3m: IM benzylpenicillin stat (if allergy - moxifloxacin&vancomycin) + IV ceftriaxone. Haem influ type b - 10 days; strep pneu - 14 days; neis menin - 7 days

Steroids (dexamethasone) IF CSF shows:

  • Purulent CSF
  • WBC >1000/uL
  • Raised CSF WCC + protein >1g/L
  • Bacteria gram stain
  • > 1m old and H. influ
  • NOT MENINGOCOCCAL

Mannitol to reduce ICP

IV saline sodium chloride 0.9% 4-2-1 maintenance

Follow up: hearing loss audiological assessment, neuro/development problems, renal failure, orthopaedic, skin, psychosocial, renal

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10
Q

Purpura fulminans: cause, manifestation and management

A

Haemorrhagic skin necrosis from DIC = acute/fatal
Thrombotic disorder, manifests as blood spots/bruising/discolouration of skin

Needs FFP, debridement or amputation

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11
Q

Viral meningitis

A

Most commonly Coxsackie group B, echovirus

Discharge home (after excluded bacterial cause) with supportive therapy (i.e. fluids)
Safety net
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12
Q

Encephalitis; what is and types

A

Inflammation of brain parenchyma

Direct invasion of cerebellum by neurotoxic virus (e.g. HSV)

Post-infectious encephalopathy of delayed brain swelling following neuroimmunological response to antigen

Slow virus infection (e.g. HIV or subacute sclerosing pan-encelphalitis follow measles). Most common: enterovirus, resp virus, HSV, VZV HHV-6

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13
Q

Signs and symptoms of encephalitis

A

Similar to meningitis; hard to distinguish; begin Tx for both
Main: fever, altered consciousness, seizures,

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14
Q

Investigations for encephalitis

A

Investigations for meningitis
LP contraindications: cardio-resp instability, signs raised ICP (coma, high BP, low HR), thrombocytopenia, focal neuro signs, coagulopathy, local infection at LP site

MRI -> hyperintense lesions, oedema, BBB breakdown

PCR for viruses

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15
Q

Management of encephalitis

A

IV acyclovir (high dose) - 3 weeks - HSV rare cause, but major complications

CMV -> add in ganciclovir and Foscarnet
VZV -> acyclovir/ganciclovir
EBV -> acyclovir

Supportive care - fluids, ventilation, etc

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16
Q

Management of encephalitis

A

IV acyclovir (high dose) - 3 weeks - HSV rare cause, but major complications

CMV -> add in ganciclovir and Foscarnet
VZV -> acyclovir/ganciclovir
EBV -> acyclovir

Supportive care - fluids, ventilation, etc

17
Q

Anaphylaxis signs and symptoms

A

Type 1 hypersensitivity; antigen cross linking with IgE membrane bound Ab of mast cell or basophill

Airway - swelling, hoarseness, stridor
Breathing - high RR, wheeze, cyanosis, SpO2 <92%
Circulation - pale, clammy, low BP, drowsy, coma
Skin - urticaria, angioedema

18
Q

Management of anaphylaxis

A

ABCDE approach, call for help, BLS may be needed
IM adrenaline ( 1:1000) in high, assess response after 5 mins; repeat if necessary
Additional:
- Establish airway + high-flow O2
- IV fluids (20mL/kg crystalloids)
- IV chlorpheniramine, 10mg (IM or slow IV)
- IV hydrocortisone, 200mg (IM or slow IV)
- Salbutamol if wheeze

19
Q

Organisms causing bacterial meningitis according to age
Neonatal - 3 months
1 month - 6 years
>6 years

A

Neonatal - 3 months

  • Group B Strep
  • E. coli and other coliforms
  • Listeria monocytogenes

1 month - 6 years

  • Neisseria meningitides
  • Strep pneumoniae
  • Haemophilus influenzae

> 6 years

  • Neisseria meningitides
  • Strep pneumoniae