Emergency Paediatrics Flashcards
(110 cards)
1
Q
Define sepsis
A
Dysregulated response to infection which may result in organ damage and death
2
Q
Pathophysiology of sepsis
A
Pro-inflammatory cascade triggered by an infection which may rapidly lead to shock, organ dysfunction and death
- systemic inflammatory response syndrome in presence of infection
3
Q
Risk factors for sepsis
A
Neonates and young babies under 3 months
Premature
History of prolonged rupture of membranes
Maternal intrapartum pyrexia
Maternal colonisation with Group B strep
Immunocompromised children - chemotherapy, immunodeficient or post transplant patients
4
Q
Features of a history indicative of sepsis
A
Fever - may be absence of hypothermia in most unwell Lethargy N+V Headache Abdo pain
5
Q
Signs on examination indicative of sepsis
A
Signs of shock = severe sepsis with shock
- hypotension
- tachycardia
- cool peripheries
- confusion
Children compensate well
- relatively well child with fever
- tachycardia - disproportionate to fever or continues post-fever
- signs of infection - crackles on chest auscultation, cellulitic skin
- non-blanching rash = meningococcal disease
6
Q
Differential diagnosis of sepsis
A
Uncomplicated infection - viral URTI
Leukaemia and aplastic anaemia - can present concurrently with sepsis
- pale, easy bruising, non-blanching rash, fever, lethargy
- picked up on blood film
Autoimmune conditions such as juvenile idiopathic arthiris - hx of rash, swollen joints, fever
7
Q
Investigations for sepsis
A
Clinical diagnosis - Raised inflammatory markers - Positive cultures or PCRs In babies under 3 with fever - FBC - CRP - blood culture - urine testing - stool culture - if diarrhoea present Find source of infection - CXR - abdominal USS - LP
8
Q
High risk features in child under 5 with fever
A
Pale, mottled, ashed or blue skin No response to social cues Appears ill Does not wake Weak, high pitched continuous cry Grunting Tachypnoea - RR>60 Moderate of severe chest indrawing Reduced skin turgor Age < 3 months, temp > 38 Non-blanching rash Bulging fontanelle Neck stiffness Status epilepticus Focal neurological signs Focal seizures
9
Q
Amber (immediate risk) factors for child under 5 with fever
A
Pallor reported by parent/career Not responding normally to social cues No smile Wakes only with prolonged stimulation Decreased activity Nasal flaring Tachypnoea - RR>50 age 6-12 months - RR>40 age >12 months O2 sats < 95% on air Crackles on chest Tachycardia - > 160 age < 12 months - > 150 age 12-24 months - > 140 age 2-5 years CRT > 3 seconds Dry mucous membranes Poor feeding in infants Reduced urine output Age 3-6 months temp > 39 Fever for > 5 days Rigors Swelling of limb/joint Non-weight bearing limb
10
Q
Low risk factors for children under 5 with a fever
A
Normal skin colour Responds normally to social cues Content/smiles Tarys awake or awakens quickly Strong normal cry/not crying Normal skin and eyes Moist mucous membranes None of the amber or red symptoms or signs
11
Q
Immediate management for sepsis in children
A
Take blood cultures
Check blood lactate
Monitor urine output - catheterise if necessary
Give high flow O2
IV/O fluids
IV/O antibiotics
Children particularly prone to hypoglycemia when unwell - corrected with 2ml/kg bolus of 10% dextrose if blood sugar < 3mmol/L
12
Q
Definitive management of sepsis in children
A
Appropriate treatment of underlying infection
Supportive care required whilst antimicrobial therapy takes effect
- may involve intensive care admission for ventilator or inotropic support
13
Q
Complications of sepsis in children
A
Long term developmental delay
Audiology defects - testing arranged on discharge
Limb ischaemia -> amputation
14
Q
Why are children at a greater risk of dehydration
A
Higher metabolic rates
Inability to communicate thirst or self-hydrate effectively
Greater water requirements per unit weight
15
Q
Causes of dehydration in children
A
Inadequate fluid intake
- structural malformation - tongue tie, cleft lip
- discomfort - oral ulcers, tonsillitis, viral pharyngitis, stomatitis
- respiratory distress
- neglect
Excessive fluid loss
- diarrhoea and/or vomiting - gastritis, gastroenteritis, pyloric stenosis, mesenteric adenitis, acute appendicitis, diabetic ketoacidosis
- excessive sweating - strenuous or prolonged physical activity, hot weather, pyrexia
- polyuria - DM, DI
- burns
16
Q
Key features of history of dehydration
A
Recent or ongoing fluid losses
Quantity of fluid loss
Are they still eating/drinking
Still urinating
17
Q
Signs of clinical dehydration
A
Appears to be unwell or deteriorating Altered responsiveness - irritable, lethargy Decreased urine output Skin colour unchanged Warm extremities Sunken eyes Dry mucous membranes Tachycardia Tachypnoea Normal peripheral pulses Normal CRT Reduced skin turgor Normal blood pressure
18
Q
Clinical signs of shock
A
Decreased level of consciousness Pale or mottled skin Cold extremities Tachycardia Tachypnoea Weak peripheral pulses Prolonged CRT Hypotension (decompensated shock)
19
Q
Red flags for dehydration in children
A
Appears unwell or deteriorating Altered responsiveness Sunken eyes Reduced skin turgor Tachycardia Tachypnoea
20
Q
Features of hypernatremic dehydration
A
More water than sodium lost from body Jittery movements Increased muscle tone Hyperreflexia Convulsions Drowsiness or coma
21
Q
Management of dehydration
A
ORS (Dioralyte) 50ml/kg over 4 hours + maintenance requirements
If not tolerating oral fluids
- NG fluids
- IV fluids
Maintenance and correction till rehydration
Investigate cause and reintroduction of normal fluid and foods
22
Q
Management of shock
A
IV/IO access 20ml/kg 0.9% normal saline
Blood for FBC, U+Es, glucose, gas, consider cultures
If not improving repeat fluid bolus, then call CICU
23
Q
When should IV fluids be given to dehydrated children
A
Shock is suspected or confirmed
Child with red flag symptoms or signs shows clinical evidence of deterioration despite oral rehydration therapy
Child persistently vomits oral rehydration solution given orally or NG
24
Q
Estimate of fluid deficit in children
A
Weight (kg) x % dehydration x 10
25
Fluid management after rehydration in children
Encourage breastfeeding and other milk feeds
Encourage fluid intake
Discourage fruit juices and carbonated drinks
In children at increased risk of dehydration consider giving 5ml/kg of ORS after each watery stool
- children under 1 year
- infants of low birth weight
- children who have passed more than 5 diarrhoeal stools in the previous 24 hours
- children who have vomited more than twice in previous 24 hours
26
Maintenance fluids for children who are nil by mouth but not yet dehyrated
0. 9% sodium chloride and 5% dextrose
- 100ml/kg for first 10kg bodyweight
- 50ml/kg for second 10kg bodyweight
- 20ml/kg for every kg above 20kg
27
Children at risk of aspiration
```
Decreased GCS
Underlying cardiac condition
Anaphylaxis
Drug ingestion
Neuromuscular disorders
Respiratory pathology
Foreign body
Post cardiac surgery
Drowning
Trauma
Medication that causes reduced GCS
Anatomical abnormality
```
28
Differential diagnoses of arrest in children
```
Choking
Opiate ingestion
Overdose of toxic substance
Decreased level of consciousness due to neurological disorder/head injury
Hypoglycemia
```
29
Algorithm for paediatric life support
```
Unresponsive
- Shout for help
- Open airway
Not breathing normally
- 5 rescue breaths
No signs of life
- 15 chest compressions
- 2 rescue breaths and 15 chest compressions
- call resuscitation team - 1 min CPR first if alone
```
30
Approach to seriously ill child
Primary ABCDE assessment and resuscitation
Secondary assessment and emergency treatment
Stabilisation and transfer
31
Stages of primary ABCDE assessment in children
```
Airway and breathing
- effort of breathing
- resp rate and rhythm
- stridor/wheeze
- auscultation
- skin colour
Circulation
- heart rate
- pulse volume
- cap refill
- skin temp
Disability
- conscious level
- posture
- pupils
Exposure
- fever
- rash
- bruising
```
32
Features of airway assessment in children
```
Head tilt chin lift
- neural in an infant
- sniffing position in child
Then try jaw thrust
In hospital adjuncts such as naso-pharyngeal airways or Guedel airways can be used
```
33
Features of breathing assessment in children
Effort of breathing
- Raised resp rate - may be caused by airway or lung pathology or driven by metabolic acidosis
- Gasping is a late sign of distress
Efficacy
- observation of chest expansion and auscultation
- silent chest most worrying
Effect of resp insufficiency
- tachycardia but will leave to bradycardia
Resuscitation
- high flow O2 through oxygen mask with reservoir bag
- if inadequate resp effort then use a bag-valve mask and consider intubation
- if patient coughing encourage coughing then 5 back blows followed by 5 chest thrusts
34
Features of circulation assessment in children
Record HR, pulse volume, cap refill time and BP
Children are good at compensating for alterations so hypotension a late sign
Resuscitation
- 20ml/kg bolus of 0.9 sodium chloride
- intraosseous access is rapid and effective - considered early if difficult cannulation
35
Features of disability assessment in children
AVPU score
- Alert
- V responds to voice
- P responds to pain
- Unresponsive
Most children will be floppy when seriously ill
- stiff posturing suggests serious brain dysfunction
Record pupil size and response to light, blood sugar
36
Features of secondary assessment in children
Reassessing response to initial resuscitative measures
Taking focused hx
Performing detailed systemd based examinations
Further investigations - blood tests, ECG, radiographs, CT
37
Diagnosis and emergency treatment of bubbling sounds on auscultation
```
D = excessive secretions
ET = suctioning
```
38
Diagnosis and emergency treatment of harsh stridor and barking cough
```
D = croup
ET = oral dexamethasone, nebulised budesonide and adrenaline in severe cases
```
39
Diagnosis and emergency treatment of soft stridors, drooling and fever
```
D = Bacterial tracheitis or epiglottitis
ET = intubation by anaesthetist followed by IV abx
```
40
Diagnosis and emergency treatment of sudden onset stridor with history of inhalation
```
D = inhaled foreign body
ET = laryngoscopy for removal
```
41
Diagnosis and emergency treatment of stridor following ingestion or injection of known allergen
```
D = anaphylaxis
ET = IM adrenaline
```
42
Diagnosis and emergency treatment of wheeze
```
D = acute asthma
ET = bronchodilators
```
43
Diagnosis and emergency treatment of bronchial breathing
```
D = pneumonia
ET = IV antibiotics
```
44
Management of congenital heart disease
May present in first few days on life in ED - heart still undergoing changes from foetal to neonatal circulation
Closure of ductus arteriosus
- presentations vary from subtle symptoms of poor feeding, sleepiness and slightly fast breathing to collapse in cardiogenic shock
If duct dependent lesion suspected IV dinoprostone should be administered
45
Management of supraventricular tachycardia
Older children present with episodes of palpitations, chest pain and dizziness
Babies may present with signs of heart failure, following prolonged episodes of SVT
Identified on 12 lead ECG
Treatment involves vagal maneuvers followed by rapid bolus of IV adenosine or synchronous DC shock
46
Management of seizures in children
Most children will present post seizure in a stable condition to ED
Status epilepticus - seizure activity ongoing at 20 mins or shorter seizures with incomplete recovery between
- Midazolam 0.5 mg/kg buccally or Lorazepam 0.1 mg/kg if intravenous access established
47
Epidemiology of choking
80% of episodes occurring in 1-3 age groups
| - peak frequency between 1-2 years
48
Risk factors of child choking
Playing with small parts
Unsupervised play and eating
Children with decreased consciousness
49
Differential diagnosis of child choking
Acute epiglottitis - sitting forward, drooling, toxic looking, temperature
Croup - coryzal symptoms, cough associated, improved with steroids/adrenaline nebuliser
Laryngomalacia - present from early age and improves with age
Whooping cough - unimmunised child, cough associated, coryzal symptoms with associated temperature
Reduced GCS - can cause stridor
50
Management of child choking
Remove foreign body if easily seen
- do not perform blind finger sweep - can push foreign body further into airway
Encourage coughing
5 back blows then 5 chest thrusts/abdominal thrusts
- check each time to see object came out
If unconscious
- open airway, 5 rescue breaths and start CPR
51
Define ALTE
Apparent Life Threatening Event
- an episode that is frightening to observer
- may include apnoea, choking or gagging, colour change or change in tone
- new term is BRUE
52
Define BRUE
Brief Resolved Unexplained Event
- an event occuring in an infant younger than 1 year when the caregiver reports a sudden brief and now resolved episode of
- cyanosis or pallor
- absent, decreased or irregular breathing
- marked change in tone
- altered level of responsiveness
53
Pathophysiology of BRUE
In 50% of patients cause is identified
| - GORD is most common cause
54
Risk factors for BRUE
Infants < 2 months old
Infants under 30 days old
Patients who were premature and previous event
55
Management of BRUE
Reassurance and observations
For low risk patients
- observation may occur in ED then safety net before discharge
For high risk patients
- refer to paediatric team for admission with investigations
56
Characteristics of DKA
Acidosis - blood pH below 7.3 or plasma bicarb below 15mmol/L
Ketonaemia - blood ketones above 3 mmol/L
Blood glucose levels generally high - above 11 mmol/L
57
Complications of DKA
Cerebral oedema
Hypokalaemia
Aspiration pneumonia
58
Pathophysiology of DKA
Starvation in midst of plenty
- blood glucose levels raised but cannot be used due to absolute deficiency of insulin
Rise in counter-regulatory hormones including glucagon, cortisol , catecholamines and growth hormone
Raises blood glucose and accelerated break down of adipose tissue
- rising level of acidic ketone bodies
Leads to osmotic diuresis so patient becomes polyuric -> dehydration
Vomiting common in DKA
59
Risk factors for DKA
```
Lack on insulin
- non-compliance with insulin treatment
- device failure
- changing insulin requirements during puberty
An excess of glucose
- increased ingestion of glucose
Intercurrent illness
- infection
```
60
Symptoms of DKA
Generally unwell and lethargic
N+V
Abdo pain
Cerebral oedema - headache, irritability, progressing to confusion, drowsiness or collapse
61
Symptoms of DM
Weight loss
Polyuria
Polydipsia
62
Clinical features of DKA
Deep, sighing breathing (Kussmaul breathing)
Tachypnoea
Subcostal and intercostal recessions
Shock - tachycardia, hypotension, increased CRT, cool peripheries
Dehydration - dry mucous membranes, sunken eyes/fontanelle and reduced skin turgor
Abdo pain
Reduced consciousness
Papilloedema
Non-specific weakness, general malaise and ketotic breath
63
Differential diagnosis of DKA
```
Hyperosmolar Hyperglycaemic State - usually occurs in DMT2
- no ketone production or acidosis
- serum osmolality > 320mosmol/kg
New presentation of T1DM
Dehydration
Sepsis
Surgical abdomen
Acidosis from renal failure or substance ingestions
```
64
Investigations for DKA
Bedside blood glucose and ketones from finger prick
- urinary ketones on dipstick
Blood gas
Lab samples - blood glucose, U&Es, FBC and creatinine
12 lead ECG
65
Levels of DKA severity
Mild - venous pH 7.2-7.3 or bicarbonate < 15mmol/L
- 5% dehydration
Moderate - venous pH 7.1-7.2 or bicarbonate < 10mmol/L
- 7% dehydration
Severe - venous pH less than 7.1 or bicarb < 5mmol/L
66
Management of DKA
Those presenting with shock 20ml/kg bolus of 0.9% saline over 15 mins
Those not in shock receive 10ml/kg bolus over 60 mins
Calculate fluid requirement
- requirement = deficit + maintenance
Insulin 0.05 or 0.1 units/kg/hour by infusion 1-2 hours after starting IV fluids
Re-evaluate
If blood glucose < 14mmol/L add 5% glucose to 0.9% sodium chloride with 20 mmol KCL per 500ml
Start subcut insulin then stop IV insulin 1 hour later
67
Resolution of DKA
Child clinically well, drinking well, tolerating food
Blood ketones < 1.0mmol/l or pH normal
Urine ketones may still be positive
68
Red flags for leg pain/limp
```
Worse
- in the morning -> inflammatory arthropathy
- at night -> malignancy
Systemically unwell - night sweats, weight loss
-> malignancy, infection, inflammatory
Redness and swelling over joint
-> infection of inflammatory
Unexplained rashes or bruises
-> coagulopathy of ?NAI
```
69
Causes of leg pain/limp in children
```
<3 years
- Toddler's fracture
3-10 years
- Transient synovitis
- Perthes' disease
10-18 years
- Slipped capital femoral epiphysis
Any age group
- Fracture
- Septic arthritis
- Osteomyelitis
- Malignancy
- Inflammatory arthropathies
```
70
Epidemiology of Toddler's fracture
9 months - 3 years of age
71
Pathology of Toddler's fracture
Minimally displaced spiral fractures of tibia
| - rarely related to NAI
72
Features of a Toddler's fracture
Unable to weight bear
Tender tibial diaphysis
Normal obs
73
Ix for Toddler's fracture
Subtle fracture on radiograph
74
Epidemiology of transient synovitis
Most common cause of hip pain in 3-10 year old
| Associated with viral upper respiratory tract infection
75
Pathology of transient synovitis
Synovial inflammation following an URTI
76
Presentation of transient synovitis
```
Afebrile
Limp
Refusal to weight bear
Groin or hip pain
Mild low grade temperature
Slightly reduced ROM
```
77
Ix for transient synovitis
Mildly raised WCC and ESR
| CRP < 20mg/L
78
Management of transient synovitis
```
Symptomatic
- simple analgesia to ease discomfort
Safety net
- if symptoms worsen or develop a fever report to A&E
- follow up at 48 hours and 1 week
```
79
Define Perthes disease
Idiopathic avascular necrosis of the femoral head
Disruption of blood flow to femoral head -> avascular necrosis of the bone
- affects the epiphysis of femur
80
Epidemiology of Perthes disease
4-12 year olds - mostly between 5-8 years
| More common in boys
81
Presentation of Perthes disease'
```
Pain in hip or groin
Limp
Restricted hop movements
Maybe referred pain to knee
Afebrile
Reduced internal rotation
```
82
Ix for Perthes' disease
```
Bloods normal
Radiograph
- sclerosis in femoral head
- fragmentation of femoral head
- widening and flattening of femoral head
MRI and bone scan
```
83
Mx of Perthes' disease
Maintain healthy position and alignment in joint and reduce the risk of damage/deformity
- bed rest
- traction
- crutches
- analgesia
Physiotherapy
- retain ROM without putting excess stress on the bone
Regular x rays
- assess healing
Surgery
- in severe cases, older children and those not healing
- improve alignment and function of femoral head and hip
84
Epidemiology of slipped capital femoral epiphysis (SCFE)
More common in boys
8-15 years
More common in obese children
85
Presentation of SCFE
Slippage of the proximal femoral growth plate
- acute or chronic
Hx of minor trauma
86
Clinical features of SCFE
```
Hip, groin, thigh or knee pain
Restricted ROM
Painful limp
Prefer to keep externally rotated hip - ROM particularly restricted internal rotation
Afebrile
```
87
Ix of SCFE
Bloods normal
Radiographs
- frog leg view required to show subtle slips
CT or MRI scan
88
Mx of SCFE
Surgery required to return the femoral head to correct position and fix it to prevent further slipping
89
Define septic arthritis
Infection inside joint
90
Epidemiology of septic arthritis
Most common in children under 4 years - can present at any age
Common and important complication of joint replacement
91
Presentation of septic arthritis
Hot, red, swollen and painful joint - only affects on joint
Refusing to weight bear
Stiffness and reduced range of motion
Systemic symptoms such as fever, lethargy and sepsis
92
Pathophysiology of septic arthritis
Haematogenous spread of microorganisms or rarely penetrating injury
93
Common bacteria causing septic arthritis
```
Staphylococcus aureus - most common
Neisseria gonorrhoea - sexually active teenageers
Group a strep - streptococcus pyogenes
Haemophilus influenza
Escherichia coli
```
94
DDx for septic arthritis
Transient synovitis
Perthes disease
Slipped upper femoral epiphysis
Juvenile idiopathic arthritis
95
Ix for septic arthris
Increased WCC, CRP > 20 and ESR
| Joint aspiration - sent for gram staining, crystal microscopy, culture and antibiotic sensitivities
96
Mx of septic arthritis
Empirical IV abx
- until microbial sensitivities known
- continued for 3-6 weeks
May require surgical drainage and washout
97
Define osteomyelitis
Infection of bone and bone marrow
98
Pathophysiology osteomyelitis
Typically occurs in metaphysis of long bones
| Commonly staphylococcus aureus
99
Presentation of ostoemyelitis
```
Can present acutely with an unwell child or chronically with subtle features
Refusing to use the limb or weight bear
Pain
Swelling
Tenderness
May be afebrile or low grade fever
```
100
Risk factors for osteomyelitis
```
Open bone fracture
Orthopaedic surgery
Immunocompromised
Sickle cell anaemia
HIV
Tuberculosis
DM
```
101
Ix of osteomyelitis
```
X-rays
- can be normal
MRI
Raised CRP, ESR and WCC
Blood culture - establish culture
```
102
Mx of osteomyelitis
Prolonged abx therapy
| Surgery for drainage and debridement of infected bone
103
Causative organisms for osteomyelitis
Neonates - Group B strep
6 months to 3 years - Kingella kingae
All ages - S.aureus and S.pneumoniae
Sickle cell disease - Salmonella spp.
104
Define osteosarcoma
Bone cancer
105
Epidemiology of osteosarcoma
Presents in adolescents and younger adults 10-20 years
| Most commonly the femur, can also be tibia and humerus
106
Presentation of osteosarcoma
```
Persistent bone pain
- worse at night time
Bone swelling
Palpable mass
Restricted joint movements
```
107
Ix for osteosarcoma
```
Urgent xray
- poorly defined lesion of the bone
- periosteal reaction - irritation of lining of bone
Raised ALP
CT/MRI scan
Bone biopsy
```
108
Mx of osteosarcoma
Surgical resection of lesion
- often with limb amputation
Adjuvant chemotherapy improves outcomes
109
Complications of osteosarcoma
Pathological bone fractures
| Metastasis
110
Causes of pyrexia of unknown origin
```
Infectious
- Kawasaki disease
- TB
- typhoid fever
- malaria
- infectious mononucleosis
- HIV
Connective tissue disorders
- juvenile idiopathic arthritis
- SLE
- sarcoidosis
Inflammatory
- UC
- crohn's disease
Neoplastic
- lymphoma
- leukaemia
Endocrine
- hyperthyroidism
Other
- factitious disorders or FII
```
