Emergency Care

Question 1

Describe the BLS algorithm for paediatric resuscitation

Answer 1

Shout for help
Open airway
5 rescue breathes if not breathing normally
Then 15 chest compressions if no signs of life

Continue rescue breaths + chest compressions at ratio of 2:15

Question 2

Which position should the head be in for optimal airway opening?

Answer 2

Infants ( < 1 year) –> neutral position

Older children –> ‘sniffing’ position

Question 3

What are the indications for commencing chest compressions/?

Answer 3

No signs of life
No pulse
HR < 60

Question 4

Where should you palpate the pulse in children?

Answer 4

Carotid, brachial or femoral

In infants –> brachial (carotid difficult due to short neck)

Question 5

What should be done if there are signs of circulatory compromise in a child?

Answer 5

Establish venous access rapidly

Give a 20ml/kg bolus of normal saline (10ml/kg in DKA)

Question 6

What should be done if rapid venous access is not possible in a child (can be very difficult to cannulate)?

Answer 6

Intraosseous access

- rapid, effective and should be considered early

Question 7

If you hear bubbling sounds on assessment of a sick child’s breathing, what should be done?

Answer 7

Suctioning for excessive secretions

Question 8

If you find a harsh stridor and a barking cough on examination, what is the emergency management?

Answer 8

Oral dexamethasone
Nebulised budesonide + adrenaline in severe cases

(croup)

Question 9

If you find a soft stridor, drooling + fever in a sick looking child, what is the diagnosis + emergency management?

Answer 9

Bacterial tracheitis or epiglottitis

–> intubation by anaesthetist followed by IV antibiotics

Question 10

If you suspect an inhaled foreign body, what would be the emergency management?

Answer 10

Laryngoscopy for removal

Question 11

If you hear bronchial breathing on examination of a sick child, which diagnosis should be considered and what is the emergency management?

Answer 11

Pneumonia –> IV antibiotics if severe

Question 12

When would you suspect a duct dependent lesion in an unwell neonate?

Answer 12

May be subtle when duct starting to close:
- poor feeding, sleepiness + slightly fast breathing
Or collapsed baby in cardiogenic shock

Question 13

If you suspect a duct dependent lesion e.g. PDA, what is the emergency management?

Answer 13

IV dinoprostone

- keeps duct open until definitive management from cardiologist

Question 14

What is the most common arrhythmia seen in children?

Answer 14

SVT

Question 15

What is the emergency management for SVT in children?

Answer 15

Vagal manoeuvres
If clinically unstable:
- rapid bolus of IV adenosine or DC shock

Question 16

What is the initial management of a choking child and when is further intervention required?

Answer 16

Encourage coughing

Further intervention if:

• child cannot speak, cry or breathe
• evidence of cyanosis
• decreased consciousness

Question 17

What is the definitive management of choking in an infant?

Answer 17

5 back blows
- holding infant face down on forearm with hand supporting jaw to keep airway open

Then 5 chest thrusts
- infant turned over, thrusts with 2 fingers at lower edge of sternum

Question 18

What is the definitive management of choking in an older child?

Answer 18

5 back blows

Then 5 abdominal thrusts (Heimlich manoeuvre)

Question 19

If a choking child becomes unconscious, what should be done?

Answer 19

Follow BLS algorithm

open airway, 5 breaths, start CPR

Question 20

What are the 3 characteristics of DKA?

Answer 20

1. Acidosis –> pH < 7.3 or bicarbonate below 18
2. Ketonaemia –> blood ketones > 3
3. Hyperglycaemia –> blood glucose usually > 11 (although some children with T1DM can develop DKA with normal glucose levels)

Question 21

What are the 3 main complications causing death in DKA?

Answer 21

Cerebral oedema
Hypokalaemia
Aspiration pneumonia

Question 22

What are the symptoms of DKA?

Answer 22

Generally unwell + lethargic
Nausea, vomiting + abdominal pain
Early cerebral oedema –> headache, irritability, confusion, drowsiness, collapse
Concurrent infection which may have precipitated DKA
If undiagnosed DM –> weight loss, polyuria, polydipsia

Question 23

What are the signs of DKA?

Answer 23

Resp:
- deep, sighing breathing (Kussmaul breathing)
- tachypnoea
- subcostal + intercostal recessions
Circulation:
- shock
- dehydration
GI:
- abdominal pain which may be severe, mimicking a surgical abdomen
Other:
- ketotic breath

Question 24

Which investigations should be done for suspected DKA?

Answer 24

Bedside blood glucose + ketones
Blood gas
Bloods: glucose, U&Es + creatinine
12 lead ECG (potassium)

Question 25

Why does management of DKA differ between children and adults?

Answer 25

Children at a much higher risk of developing cerebral oedema in the rehydration phase of treatment

Question 26

What is the management for DKA in children?

Answer 26

ABCDE IV fluid replacement Followed by addition of IV insulin infusion

Question 27

Which fluid is used for replacement in DKA?

Answer 27

0.9% sodium chloride with 20mmol of potassium in each 500ml bag

Question 28

When should insulin be given in the management of DKA?

Answer 28

Delay IV insulin for 1-2 hours after beginning IV fluid therapy

Question 29

Which electrolyte abnormality is it vital to monitor for in DKA?

Answer 29

Hypokalaemia

Question 30

Which investigations should be done for a baby < 3 months with a fever?

Answer 30

``` FBC CRP Blood culture Urine testing Stool culture if diarrhoea present Lumbar puncture if looks unwell ```

Question 31

What is the initial management for suspected sepsis in a child?

Answer 31

Sepsis 6: - blood cultures - lactate - urine output - high flow oxygen - IV/IO fluid - IV/IO antibiotics Children prone to hypoglycaemia when unwell --> if glucose < 3, give 2ml/kg blue of 10% dextrose

Question 32

What are the most common causes of dehydration in children?

Answer 32

Excessive fluid loss: - diarrhoea +/- vomiting (most common) - excessive sweating - polyuria (T1DM, diabetes insipidus) - burns Inadequate fluid intake: - structural malformation e.g. tongue tie - discomfort e.g. ulcers, tonsilitis - respiratory distress - neglect

Question 33

What are the red flag signs/symptoms for dehydration?

Answer 33

``` Appears unwell or deteriorating Altered responsiveness Sunken eyes Reduced skin turgor Tachycardia Tachypnoea ```

Question 34

How is rehydration carried out in a dehydrated child?

Answer 34

Oral rehydration solution (ORS) 50ml/kg fluid deficit + maintenance fluids - oral or NG tube IV fluids

Question 35

When are IV fluids indicated for rehydration?

Answer 35

Shock is suspected or confirmed Red flag symptoms or signs Deteriorating despite oral rehydration therapy A child persistently vomits the ORS