Acutely ill child

Question 1

risk factors for NAI

Answer 1

history of intimate partner violence and abuse
substance abuse in caregiver
mental health condition in caregiver
excessive crying
unintended pregnancy
developmental problems

Question 2

presentation of NAI

Answer 2

bruises
bites
lacerations/abrasions
thermal injuries
fractures
intracranial injuries
eye trauma
spinal/ visceral injuries

Question 3

differentials of NAI

Answer 3

coagulopathy
osteogenesis imperfecta

Question 4

skeletal survey in NAI

Answer 4

Head/chest (including AP and lateral skull)

Spine/pelvis

Upper limbs

Lower limbs

Skeletal survey should be repeated at 11-14 days.

This is to ensure that injuries too new to appear on the initial skeletal survey are detected.

11-14 days is used as this is the maximal time take for the periosteal reaction to occur, allowing fractures to be visualised on X-ray.

Question 5

possible physical presentations of child abuse

Answer 5

bruising

fractures: particularly metaphyseal, posterior rib fractures or multiple fractures at different stages of healing

torn frenulum: e.g. from forcing a bottle into a child’s mouth

burns or scalds

failure to thrive

sexually transmitted infections e.g. Chlamydia, Gonorrhoea, Trichomonas

Question 6

features where you should consider child neglect abuse

Answer 6

Severe and persistent infestations (e.g. Scabies or head lice)
Parents who do not administer essential prescribed treatment
Parents who persistently fail to obtain treatment for tooth decay
Parents who repeatedly fail to attend essential follow-up appointments
Parents who persistently fail to engage with child health promotion
Failure to dress the child in suitable clothing
Animal bite on an inadequately supervised child

Question 7

features where you should suspect neglect child abuse

Answer 7

Failure to seek medical advice which compromises the child’s health
Child who is persistently smelly and dirty
Repeat observations that:

poor standards of hygiene that affects the child’s health

inadequate provision of food

living environment that is unsafe for the child’s development stage

Question 8

features where you should consider sexual abuse

Answer 8

Persistent dysuria or anogenital discomfort without a medical explanation
Gaping anus in a child during examination without a medical explanation
Pregnancy in a young women aged 13-15 years
Hepatitis B or anogenital warts in a child 13-15 years

Question 9

features where you should suspect sexual abuse

Answer 9

Persistent or recurrent genital or anal symptoms associated with a behavioural or emotional change
Anal fissure when constipation and Crohn’s disease have been excluded as the cause
STI in a child younger than 12 years (where there is no evidence of vertical or blood transmission
Sexualised behaviour in a prepubertal child

Question 10

features where you should consider physical abuse

Answer 10

Any serious or unusual injury with an absent or unsuitable explanation
Cold injuries in a child with no medical explanation
Hypothermia in a child without a suitable explanation
Oral injury in a child with an absent or suitable explanation

Question 11

features where you should suspect physical abuse

Answer 11

Bruising, lacerations or burns in a child who is not independently mobile or where there is an absent or unsuitable explanation
Human bite mark not by a young child
One or more fractures if there is an unsuitable explanation, including:

fractures of different ages

X-ray evidence of occult fractures

Retinal haemorrhages with no adequate explanation

Question 12

high risk colour

Answer 12

pale
mottlesd
ashen
blue

Question 13

high risk activity

Answer 13

no response to social cues
appears ill to a healthcare professional
doesn’t wake or if roused doesn’t stay awake
weak, high-pitched or continuous cry

Question 14

high risk respiratory

Answer 14

grunting
tachypnoea, RR>60
moderate or severe chest indrawing

Question 15

high risk circulation and hydration

Answer 15

reduced skin turgor

Question 16

other high risk features

Answer 16

age <3 months
temperature >38
non-blanching rash
buldging fontanelle
neck stiffness
status epilepticus
focal neuro signs
focal seizures

Question 17

CT head criteria <1 hour

Answer 17

Suspicion of non-accidental injury

Post-traumatic seizure but no history of epilepsy.

On initial emergency department assessment, GCS less than 14, or for children under 1 year GCS (paediatric) less than 15.

At 2 hours after the injury, GCS less than 15.

Suspected open or depressed skull fracture or tense fontanelle.

Any sign of basal skull fracture (haemotympanum, ‘panda’ eyes, cerebrospinal fluid leakage from the ear or nose, Battle’s sign).

Focal neurological deficit.

For children under 1 year, presence of bruise, swelling or laceration of more than 5 cm on the head

Question 18

Paediatric BLS compression ratio

Answer 18

15:2

Question 19

paediatric BLS

Answer 19

unresponsive?

shout for help

open airway

look, listen, feel for breathing

give 5 rescue breaths

check for signs of circulation

infants use brachial or femoral pulse, children use femoral pulse

15 chest compressions:2 rescue breaths (see above)

chest compressions should be 100-120/min for both infants and children

depth: depress the lower half of the sternum by at least one-third of the anterior–posterior dimension of the chest (which is approximately 4 cm for an infant and 5 cm for a child)

in children: compress the lower half of the sternum

in infants: use a two-thumb encircling technique for chest compression

Question 20

causes of paediatric cardiac arrest

Answer 20

Causes could include birth asphyxia, inhalation of foreign body, acute asthma or bronchiolitis. Respiratory arrest can also be secondary to neurological dysfunction or ingestion of drugs such as opiates.

Question 21

pathophysiology of cardiac arrest in children

Answer 21

The outcome of cardiac arrest in children is poor. In children, the most common cause of cardiorespiratory arrest is due to a respiratory problem causing prolonged hypoxaemia resulting in cardiac arrest. At the point of arrest the organs, including the brain, have experienced significant hypoxic damage; a primary cardiac cause is very rare.

Question 22

risk factors for children at risk of aspiration

Answer 22

decreased GCS

an underlying cardiac condition

anaphylaxis

drug ingestion

neuromuscular disorders

respiratory pathology

foreign body

post cardiac surgery

drowning

trauma

medication that causes a reduction in GCS

any anatomical abnormality with the ability to obstruct the airway

non accidental injury (see our child protection article for more information)

Question 23

airway opening manoeuvre for <1 year infant

Answer 23

neutral position

Question 24

airway opening manoeuvre for older children

Answer 24

sniffing morning air