Paediatric Assessment

Question 1

Meningitis

Answer 1

Viral most common or bacterial (septicaemia).

Caused by meningococcal, pneuomococcal, TB.

Meningococcal - 50% fatal, 10% severe (WHO, 2018).

S/S - fever, photophobia, rash, stiff neck, headaches, seizures, fatigue.

90% of deaths w/in 24hrs (Meningitis UK).

Question 2

What are the two tests for Meningitis?

Answer 2

Kernig’s - flex leg at 90deg, extend knee up, +ve if pain in lower back and leg.

Brudzinski’s - chin to chest, hips/knees flex due to pain.

Question 3

Describe what is meant by Meningococcal Septicaemia.

Answer 3

Meningococcal bacteria release toxins into the blood.

Attack endothelium of vessels.

-> leak -> red. blood vol -> red. O2 carrying capacity -> circulation shunts centrally -> cold peripheries/pallor/tachypnoea.

Question 4

Kawasaki Disease.

Answer 4

Affecting <5y/o mainly.

5/7 - fever w/ rash/lymphodenopathy/strawberry tongue/swollen hands & feet/dry lips.

Tx ALWAYS in hosp - IV immunoglobulin & aspirin.

Complications - vasculitis, can affect coronary arteries (1/4 w/out tx).
3% mortality.
(NHS).

Question 5

Briefly describe the paediatric assessment triangle.

Answer 5

Appearance: TICLS - Tone, Interactiveness, Consolability, Look/Gaze, Speech/Cry.

WOB: nostril flaring, tracheal tug, IC/sternal recess, accessory muscles, abdo breathing, sounds, positioning.

Circulation: CRT, colour, mottling, rashes, pulses, fluid loss (blood/burns/dehyd), cyanosis (sats <85% - Yon et al., 2022).

Question 6

Paediatric Rashes

Answer 6

Acute or chronic.
Blisters + itchy = urticaria (environment, food, viral).
Blister + yellow crust = impetigo.
Petechial/purpuric - non-blanch = CONCERN.
Check armpits, buttocks, nappy line, groin, legs.
Causes - chick pox, meals, heat, hives, scarlet fever.

Question 7

Lymphadenopathy in Paediatrics.

Answer 7

Cervical:
Tonsilitis, pharyngitis, sinusitis, glandular fever, TB.

Generalised:
Febrile illness, systemic juvenile chronic arthritis, acute lymphatic leukaemia, dry reaction, Kawasaki.

Question 8

What are the signs of sepsis in paediatrics?

Answer 8

Tachypnoea.
Seizures.
Mottling/pallor/cyanosis.
Rash.
Lethargy/red. GCS.
Cold.
Red. oral intake.
Vom.
Red. UO/not PO for >12hrs.

Question 9

List some red flags in paediatrics.

Answer 9

Fever >38.0
Drowsy.
Cold peripheries.
Petechial rash.
Stiff neck.
SOBAR.
Tachycardia.
Tachypnoeic.
Hypotension (terminal sign).

Question 10

How do you assess pain in paediatrics?

Answer 10

Wong-Baker FACES Pain Rating Scale.

Question 11

Outline fever in paediatrics

Answer 11

Generally 38.0+.
<3mths - 38.0+ sig.
3-6mths - 39.0+ sig.

Red flags -
+ rash.
+ dehydration.
+ fatigue.

Question 12

What are the signs of dehydration in infants?

Answer 12

Dark urine.
Red. UO.
Sunken fontanelle.
Pyrexia.
Dry mouth/tongue/skin.
Constipation.

Question 13

List the signs of physical abuse.

Answer 13

Injuries at diff healing stages.
Freq minor injuries, inadequate explanation.
Other abuse signs - neglect, fail to thrive.
Non-acc sites.
Child discloses.
Unusual behaviour w/ parent.
Child fearful of parents.

0.5m children abused p/a in UK (NSPCC).

Question 14

List the signs of dehydration in older children.

Answer 14

Dry mouth.
Cracked lips.
Irritable.
Lack of tears when crying.
Dark urine.
Red. UO.
Constipation.
Poor concentration.
Headaches.
Drowsy.
Dizzy.

Question 15

List some common sites for NAI.

Answer 15

Eyes.
Cheek - bruising/finger marks.
Mouth - torn frenulum.
Ears - pinch/slap.
Neck, shoulder, upper/inner arm, chest - bruising, grab marks.
Skull # - ICH -> Shaken Baby Syndrome - subdural haematoma, SAH - American Association of Neurosurgeons.

Question 16

Why are observations different in paediatrics?

Answer 16

RR: ^ as ^ metabolic demand, smaller functional residual capacity (Saikia & Mahanta 2019).

HR: ^ metabolic demand, smaller SV so ^ HR to compensate & give adequate CO (BMJ).

BP: red. - red. SVR + smaller vessels.

Question 17

Important paediatric history to gain.

Answer 17

Maternal:
Ante&postnatal, birth route/complications, pregnancy complications, prem?

Immunisations:
What? When?

Development:
Milestones? Delays?

Drug Hx:
Regular? Prescribed? Recent short courses (abx, steroids), maternal drugs?

FHx & SHx:
Lives w/? Smokers at home? Pets? Similar symptoms in 1st/2nd degree relatives? School? Social services/health visitor?

Question 18

Paediatric Anatomical Differences in Airway:

Answer 18

Smaller diameter & length.
Large tongue in smaller oropharynx.
Funnel shape.
Young - narrowest just below glottis (cricoid cartilage).
Anterior larynx.
Epiglottis is long, narrow, floppy & horseshoe shape.
Large occiput (+ tongue = easy obstructed).

Question 19

Paediatric Anatomical Differences in Breathing:

Answer 19

Infants are obligatory nasal breathers.
Faster to exhaustion.
^ RR.
^ Metabolic demand.
Ribs horizontal (only move up in insp).
Ribs flat not arched.
Compliant chest wall allows sternal recess.
Diaphragmatic breathers as most effective resp muscle.

Question 20

Paediatric Anatomical Differences in Circulation:

Answer 20

SVR lower - NIBP often inaccurate but will be lower.
Greater subcut tissue + small veins = hard to cannulate.
Arrest - usually resp (healthy CVS - PEA/Asys).
Circulatory vol - vol/kg is proportionately larger -> haem is more serious (100ml in 5kg baby = 10% vol).
Hypotension - late, terminal sign.

Question 21

Topics to cover in paediatric assessment:

Answer 21

Meningitis.
Septicaemia.
Dehydration.
Rash.
Fever & fatigue.
Pain ax.
System ax - Resp/CVS/GI/Neuro.
NAI/Safeguarding/Welfare.
Plan.

Question 22

Bronchiolitis.

Answer 22

<2y/p - usually viral.

S/S: ^RR, cold symptoms, red. oral intake, cough, crackles, wheeze.

Features: fever, consider pneumonia if 39.0+ or persistent focal crackles.

Tx: DO NOT GIVE abx or salbutamol (NICE 2015) - doesn’t improve LOS in hosp/Sats, side effects (^HR etc) outweigh any benefit of B2-agonists (Cai et al., 2020).

Question 23

Croup.

Answer 23

6mths - 3yrs.

S/S: seal bark cough, hoarse voice, DIB, rasping on insp, cold-like symptoms, fever.

Red Flags: resp retractions, cyanosis, lethargy, v’ ^T.

Night time symptoms worse.

(NHS).