2- Emergency paediatrics (2/2) Flashcards

Question

management of pneumothorax

Answer 1

- If asymptomatic: none - If symptomatic o Give oxygen as required o Needle aspiration (2nd intercostal mid clavicular) o Chest drain (4th mid axillary) o In an emergency do a needle aspiration before chest drain

Answer 2

- Insert a 21-23G butterfly into affected side at the **2nd intercostal space in the midclavicular line** - Butterfily can be placed under water following insertion

Answer 3

* Lie the child supine with the affected side raised by 30–45° using a towel. * Raise the arm towards the head. * Suitable sites are the **fourth intercostal space in the mid-axillary line** (be careful to avoid the nipple), and second intercostal space in mid- clavicle line. * Chest drain insertion should be performed using strict aseptic technique. * Wash hands and put on sterile gloves, gown, +/– surgical mask. * Clean skin over the insertion site with antiseptic solution. * Prepare sterile field, then infiltrate small amount of local anaesthetic into the tissues down to the pleura. * Wait 1–2min, then make a small skin incision with the scalpel just above and parallel to rib. Note: Blood vessels lie just below each rib. * Using artery forceps make a blunt dissection down to and through the parietal pleura. * Using forceps clamp chest drain and then insert into pleural space. Most clinicians remove the trocar before insertion. * Aim to push the chest drain tip towards the lung apex. In the event of a small pneumothorax aim the tip in the direction of the pneumothorax remembering to aim anteriorly (air rises in the ill child lying supine). * Connect the drain tightly to the underwater drainage system, unclamp drain, and apply negative pressure of 5–10cmH2O. Bubbling should start to occur.

Answer 4

<2.6mmol/l

Answer 5

- Hypoglycaemia is a sign of underlying disease that interferes with at least one of the following processes: o Carbohydrate intake o Carbohydrate absorption o Gluconeogenesis o Glycogenolysis - **Gluconeogenesis** is a metabolic pathway that results in the generation of glucose from non-carbohydrate substrates e.g pyruvate, lactate, glycerol. It mainly occurs in the liver but also to some extent in the cortex of the kidneys. The process occurs during periods of fasting, starvation, low-carb diets or intense exercise. It is often associated with ketosis. - **Glycogenolysis** is the breakdown of glycogen and takes place in the cells of muscle (to provide energy for contraction) and hepatocytes (to release glucose into the bloodstream for uptake by other cells).

Answer 6

**Systemic/Nutrition** * Starvation * Malnutrition * Sepsis * Malabsorption **Metabolic** * Ketotic hypoglycaemia “accelerated starvation” * Glycogen storage disease * Galactosaemia * Organic acidaemia * Carnitine deficiency * Acyl CoA Dehydrogenase deficiency **Endocrine** * Hyperinsulinism * Hypopituitarism * Growth hormone deficiency * Hypothyroidism * Congenital adrenal hyperplasia **Hepatic** * Hepatitis * Cirrhosis * Reye Syndrome **Toxic** * Aspirin * Alcohol * Insulin * Valproate

Answer 7

- BM - Urine: ketones

Answer 8

**If Patient can tolerate oral fluids** - 50ml of Lucozade or glucogels - Recheck BM in 15 mins **<2.6mmol/l** (IV bolus of dextrose or IM glucagon) **Patient unable to tolerate oral fluids** - IV access: IV bolus 2ml/kg 10% dextrose followed by continuous infusion 3-5ml/kg/hr 10% dextrose **No IV access- IM glucagon** - Aim BM 4-8mmol - All patients with hypoglycaemia of unknown origin require admission

Answer 9

Wide spectrum of nutritional disorders, varying from protein-energy mal nutrition to micronutrient nutritional deficiencies t - Common cause of child mortality and morbidity

Answer 10

- Diets low in protein, energy or specific nutrients - Strict fad or vegetation diets - Disease causing malabsorption (coeliac, CF, crohns disease) - Eating disorders e.g. anorexia nervosa

Answer 11

- Recent weight loss (t10% over 3mths is suggestive of impaired nutritional status). - Accurately plot serial height and weight (falling across 2 centile lines or below 3rd centile may indicate nutritional impairment). - Percentage weight for height (= [actual weight/expected weight for height centile] x 100); a value of d90% may indicate impairment. - Body mass index (BMI) = weight (kg)/height (m)2. - Mid-arm circumference divided by head circumference (malnutrition if <0.31). - Detailed dietary assessment of 5–7-day food diary. - Serum albumin.

Answer 12

Presentation * Not growing or putting on weight at the expected rate (faltering growth) * Changes in behaviour, such as being unusually irritable, slow or anxious * Low energy levels and tiring more easily than other children

Answer 13

Characterised by bilateral pitting oedema, in the absence of another medical cause of oedema - Typically associated with dietary protein deficiency - Most often seen in sub-saharan Africa - Can be seen in children with severely restricted diets (children with ASG) - Typically occurs at the time of weaning and up to 5 years of age

Answer 14

- Infection - Hypoglycaemia - Hypothermia - Xerophthalmia - Electrolyte disturbance - Cardiac failure

Answer 15

- Urine dipstick - FBC - Serum electrolytes - Serum protein

Answer 16

- Fluids - Oral calorie intake restricted to maintenance requirements (prevent refeeding) - Antibiotic therapy

Answer 17

* Severely ill patients, e.g. ill preterm infants. * Nutritional supplementation is required, e.g. FTT, cystic fibrosis. * Swallowing difficulty, e.g. severe cerebral palsy. * Metabolic diseases, e.g. phenylketonuria. * Gastrointestinal failure, e.g. malabsorption, short bowel syndrome. * Other primary disease state, e.g. chronic renal failure.

Answer 18

oral supplementation enteral tube feeding parenteral

Answer 19

high energy milks, mineral/vitamin supplementation

Answer 20

* Can be: NG, orogastric, nasojejunal and gastrostomy * Liquid foods are given as boluses or continuously e.g. overnight Indication * Swallow problems (severe cerebral aplsy, prematurity) * Cardiorespiratory compromise * GORD * Anorexia

Answer 21

e.g. TPN - Indication: post op, treatment of IBD, oral feeds contraindicated e.g. NEC, intestinal failure e.g. short bowel syndrome, GI obstruction, oncology e.g. graft versus host

Answer 22

Complications * Sepsis: usually S. epidermidis, S. aureus, Candida, Pseudomonas, E. coli. * Demanding: in expertise, cost, etc. * Central-line: occlusion, breakage, displacement. * Electrolyte/metabolic disturbances: e.g. glucose i or d. * Vascular: thrombophlebitis, thromboembolism, extravasation injuries. * Cardiac tamponade: avoid by placing IV line tip proximal to right atrium. * From amino acids: PN-associated liver disease, including, steatosis, cholestasis, or, rarely cirrhosis or portal hypertension. * From lipids: platelet dysfunction, hyperlipidaemia, fatty liver, pulmonary hypertension. * Metabolic bone disease: due to insufficient Ca2+ and PO43 –.

Answer 23

- Body temp <35 degrees --> In trauma patients <36 (hypothermic trauma patients can have devastating consequences) Classified as mild, mod or severe according to clinical features - Mild 32-35 - Mod – 28-32 - Sev -<28

Answer 24

o Compensation o Decompensation o Failure of body’s defences against cold

Answer 25

- Neonates and young children - Hypothyroidisms - General anaesthetics use

Answer 26

- Not enough clothes in cold weather - Staying outside too long - Fall into cold water - Wet clothes - Live in cold house

Answer 27

- Core body temp measurement - 12 lead ECG - UandE

Answer 28

Osborn wave – notch in the downward portion of R wave in QRS complex

Answer 29

- Cold exposure - Body temp <35 degrees - Shivering - Impaired mental state - **Mild**: Tachypnea, tachycardia, hypertension - **Moderate**: resp depression, bradycardia, hypotension - **Severe**: coma and apnea

Answer 30

**Initial** - Stop further cooling - Remove patient from cold environment - Remove wet or cold clothing - Insulate - Warming of body - Secure airway - Monitor breathing and circulating - Maintaining circulating using warm IV fluid **Rewarming** - **Passive**: remove cold and wet clothing and apply dry insulation e.g. blankets - **Active** external warming e.g. forced air rewarming, radiant heat and chemical heat packs Beware: active external rewarming may be ineffective and harmful in patients with severe hypothermia or absent circulation

Answer 31

Body temp >40 degrees - Occurs when the body absorbs or generates more heat than it can release - different types

Answer 32

Heat cramps Heat exhaustion Heat rash Heat stress Heatstroke

Answer 33

- Heat stroke e.g. overexertion in hot, humid conditions

Answer 34

Risk factors - Children – may play in the heat without taking time to rest, cool off and stay hydrated - Dehydration - CF

Answer 35

- Rectal thermometer/ oesophageal probe in intubated patients - FBC - Liver function tests - U&Es

Answer 36

Presentation - >40 degrees - Irritability - Confusion - Coordination issues - Flushes skin - Dizziness, syncope - Low blood pressure - Reduced sweating (heat stroke) - Tachycardia/ tachypnoea - Seizures - Intense thirst

Answer 37

- Stop physical activity, remove heavy or tight clothing - Drink electrolyte drink/ IV fluids - Cool compresses/ col or ice water immersion

Answer 38

- Take cool breaks in the shade - Stay well hydrated - Wear light weight, light colour clothing

Answer 39

Hyperthermia isn’t the same as a fever. When you have hyperthermia, your body temperature rises above a certain “set-point” that’s controlled by your hypothalamus (a part of your brain that controls many body functions). But when you have a fever, your hypothalamus actually increases your body’s set-point temperature. This intentional rise in body temperature is your body’s attempt to fight off an illness or infection.

2- Emergency paediatrics (2/2) Flashcards

(69 cards)