Paediatric Emergencies Flashcards
Systemic inflammatory response syndrome (SIRS) criteria
Generalised inflam response, defined by presence of ≥2 criteria including either abnormal temp or WCC as one:
Abnormal core temp (<36, >38.5) Abnormal HR (>2.5 SD above normal rate or less than 10th centile for child <1) Raised RR (>2.5SD above normal for age or mechanical ventilation for acute lung disease) Abnormal WCC in circulating blood (above or below normal range or >10% immature cells)
Paeds BLS, neonatal resus
Sepsis, severe sepsis and septic shock
Sepsis - SIRS in the presence of infection
Severe sepsis - sepsis in the presence of CV dysfunction, resp distress syndrome or dysfunction ≥2 organs
Septic shock - sepsis with CV dysfunction persisting after at least 40ml/kg fluid resus in one hour
Common causative organisms of sepsis
GBC and E.coli, Listeria monocytogenes - early onset neonatal sepsis
Coagulase-negative staphyloccocus (CoNS) (e.g. staph epidermidis - late onset neonatal sepsis
Others: staph aureus (coagusate +ve), strep pneumoniae, non-pyogenic strep, Neisseria meningitidis
Investigations and management
Investigations: clinical suspicion diagnosis and blood; may also be neonatal sepsis RFs - PROM/PPROM, chorioamnionitis (fever duing labour)
Management:
Peads sepsis 6 within 1 hr, transfer to acute setting
IV access - if failed after 2 attempts, gain IO access
LP if: <1m old, 1-3m who appear unwell, 1-3m with WCC <5 or >15x10^9/L
IV fluid resus + 20ml/kg 0.9% NaCl bolus over 5-10 mins
Bloods - clotting ( can be DIC in sepsis), culture, CRP (may take 12-24 hrs to rise), VBG (including glucose and lactate), FBC, U&E+creatinine
CXR, urine dip on MSU
Abx within 1 hr
If meningococcal sepsis -IM benzylpenicillin (community) or IV cefotaxime (in hosp)
Other early onset <72 hrs - GBS, L. monocyto, E.coli - IV cerotaxime+amikacin+ampicillin
Other late onset >72 hrs - CoNS (s. epidermidis) - IV meropenem+amikacin+ampicillin
Signs and symptoms of meningitis
Bulging fontanelle, hyperextension of neck and back (opisthotonos)
Headache, photophobia, neck stiffness, fever
- Kernig’s sign - pain on leg straightening
- Brudzinski’s sign - supine neck flexion -> knee/hip flexion
Lethargy, drowsiness, non-blanching rash
HR starts high to compensate ischaemia in brain, then drops as baroreceptos in heart sense high BP
Raised ICP symptoms (late signs) - Cushings triad: high BP, low HR, irregular RR
Investigations for suspected meningitis
LP (unless concerned about raised ICP, in which case do CT first)
Blood culture
FBC, CRP, U&E and glucose
Coagulation profile
Further immuno analysis (complement deficiency) if >1ep
Management of bacterial meningitis; child >3m
Admit, sepsis 6
Abx
- <3m: IV cefotaxime + IV amoxicillin/ampicillin
- > 3m: IM benzylpenicillin stat (if allergy - moxifloxacin&vancomycin) + IV ceftriaxone. Haem influ type b - 10 days; strep pneu - 14 days; neis menin - 7 days
Steroids (dexamethasone) IF CSF shows:
- Purulent CSF
- WBC >1000/uL
- Raised CSF WCC + protein >1g/L
- Bacteria gram stain
- > 1m old and H. influ
- NOT MENINGOCOCCAL
Mannitol to reduce ICP
IV saline sodium chloride 0.9% 4-2-1 maintenance
Follow up: hearing loss audiological assessment, neuro/development problems, renal failure, orthopaedic, skin, psychosocial, renal
Management of bacterial meningitis; child >3m
Admit, sepsis 6
Abx
- <3m: IV cefotaxime + IV amoxicillin/ampicillin
- > 3m: IM benzylpenicillin stat (if allergy - moxifloxacin&vancomycin) + IV ceftriaxone. Haem influ type b - 10 days; strep pneu - 14 days; neis menin - 7 days
Steroids (dexamethasone) IF CSF shows:
- Purulent CSF
- WBC >1000/uL
- Raised CSF WCC + protein >1g/L
- Bacteria gram stain
- > 1m old and H. influ
- NOT MENINGOCOCCAL
Mannitol to reduce ICP
IV saline sodium chloride 0.9% 4-2-1 maintenance
Follow up: hearing loss audiological assessment, neuro/development problems, renal failure, orthopaedic, skin, psychosocial, renal
Purpura fulminans: cause, manifestation and management
Haemorrhagic skin necrosis from DIC = acute/fatal
Thrombotic disorder, manifests as blood spots/bruising/discolouration of skin
Needs FFP, debridement or amputation
Viral meningitis
Most commonly Coxsackie group B, echovirus
Discharge home (after excluded bacterial cause) with supportive therapy (i.e. fluids) Safety net
Encephalitis; what is and types
Inflammation of brain parenchyma
Direct invasion of cerebellum by neurotoxic virus (e.g. HSV)
Post-infectious encephalopathy of delayed brain swelling following neuroimmunological response to antigen
Slow virus infection (e.g. HIV or subacute sclerosing pan-encelphalitis follow measles). Most common: enterovirus, resp virus, HSV, VZV HHV-6
Signs and symptoms of encephalitis
Similar to meningitis; hard to distinguish; begin Tx for both
Main: fever, altered consciousness, seizures,
Investigations for encephalitis
Investigations for meningitis
LP contraindications: cardio-resp instability, signs raised ICP (coma, high BP, low HR), thrombocytopenia, focal neuro signs, coagulopathy, local infection at LP site
MRI -> hyperintense lesions, oedema, BBB breakdown
PCR for viruses
Management of encephalitis
IV acyclovir (high dose) - 3 weeks - HSV rare cause, but major complications
CMV -> add in ganciclovir and Foscarnet
VZV -> acyclovir/ganciclovir
EBV -> acyclovir
Supportive care - fluids, ventilation, etc
