Paediatric emergency medicine

Question 1

when should a parent send in their child to ED to get their plaster cast checked?

Answer 1

the cast is cracked, soft, loose or tight, or has rough edges that hurt

you are worried that an object has been pushed inside the cast

there is an offensive smell or ooze coming from the cast

there is increasing pain–> signs of compartment syndrome

Question 2

what are some general practice principles about plaster cast care?

Answer 2

1. keep dry as much as possible
2. do not stick things into the cast to scratch
3. try not to bend it in the first 24hrs as it hardens
4. do not remove the inside fluffy layer of the cast- exposing the skin directly to the plaster

Question 3

what consists of a full septic work up for an unwell neonate?

Answer 3

FBE, blood culture, urine culture ± CXR (if respiratory symptoms or signs) ± LP

Question 4

what should we do for a child with impaired conscious state, focal neurological signs or who is haemodynamically unstable?

Answer 4

working diagnosis= meningitis/encephalitis

so immediate management with IV or IM ceftriaxone or benzylpenicillin

+/- dexamethasone

Question 5

what are some examination features of meningitis in a child?

Answer 5

In infants, the fontanelle may be full

Neck stiffness may or may not be present (not a reliable sign in young children)

A purpuric rash is suggestive of meningococcal septicaemia

Kernig’s sign: hip flexion with an extended knee causes pain in the back and legs

CSF shunts, spinal and cranial abnormalities (eg dermal sinuses) which may have predisposed a child to meningitis

Signs of encephalitis: altered conscious state, focal neurological signs

Question 6

what are some follow up practice points for young children with diagnosed bacterial meningitis?

Answer 6

All children with bacterial meningitis should have a formal audiology assessment 6-8 weeks after discharge (earlier if there are concerns regarding hearing).

Neurodevelopmental progress should be monitored in outpatients.

Question 7

acute management of open fracture?

Answer 7

• Fast the patient
• Morphine IV
• Tetanus status- ADT? Or Tetanus antibodies?
• IV antibiotics
• Immobilise fracture for pain management
Direct pressure on the bleeding vessel with blood loss apparent.

Question 8

what is the significance of stridor/wheeze in a burns patient?

Answer 8

indicates where the injury is in the airway;

stridor= high (extrathoracic obstruction), wheeze = low (intrathoracic obstruction)

Question 9

what management might we consider for a circumferential chest burn and why?

what about a circumferential burn for a limb like a leg or an arm?

Answer 9

an escharotomy; if its 3rd degree full thickness burn

this involves cutting the burned skin as it is restricting their ventilation

again consider escharotomy if you feel the burn is acting like a torniquet around the limb

Question 10

how might we neutrally align the cervical spine of a child?

Answer 10

place 1-2 towels beneath buttock or back

this is because the child’s occiput is larger than the adult

Question 11

what manoeuvre do we use to open a child’s airway?

Answer 11

jaw thrust (not chin lift or head tilt)

Question 12

a child comes into ED and you suspect gastroenteritis. the child is unwell looking and dehydrated. you commence fluid resuscitation. 24 hrs later, the child is still unwell. what do you do?

Answer 12

immediate surgical referral to rule out appendicitis and intussusception

Question 13

what is glue used for wound healing in ED?

Answer 13

glue= dermabond= cyanoacrylate= tissue adhesive that replaces sutures for small superficial lacerations

Question 14

how is glue applied to a wound?

Answer 14

1. LA if required
2. Clean wound with n.saline
3. bring wound edges together
4. break vial and apply glue over (NOT INTO) the wound line
5. Let dry for 2mins
6. Apply second layer +/- steristrips if required
7. let dry again for 2mins
8. advise no picking at the glue adhesive, it will fall off itself. No scrubbing or applying lotions to the glue- pat dry if wet.

Question 15

at what age are you seriously concerned about a child with a fever and what do you do?

Answer 15

less than 3 months old (but really now guidelines say less than 1 month) with a fever

bring them straight into the ED for a full septic work up

Question 16

what is always abnormal in the CSF of a patient with suspected bacterial meningitis regardless of age?

Answer 16

presence of polymorphs/neutrophils is always abnormal

Question 17

A girl is BIBA to ED with hypotension, fever and diffuse erythroderma and altered conscious state; paramedics report they found and removed a retained tampon. you automatically think toxic shock syndrome. what is your acute management?

Answer 17

1. If the tampon had not been removed, remove it.
2. Drain any abscesses.
3. Aggressive fluid resuscitation and transfer to ICU.
4. Empiric antibiotics initially then clindamycin + penicillin (consider vancomycin or flucloxacillin for staph)
5. Surgical debridement.

Question 18

how do we diagnose staphyloccocal scalded skin syndrome?

Answer 18

clinical diagnosis only

Painful erythema in flexures/buttocks (intertriginous areas)
Also in perioral area
Short blistering phase
Fever

seen in NEONATES/young children

Question 19

what is the management of HSP in ED?

Answer 19

1. Rule out bleeding disorders, sepsis, meningoccocal disease
2. Check urine, UEC
3. Give steroids for acute management
4. Usually self-limiting without much complication; supportive care such as analgesia
5. Organise renal follow up and monitoring

Question 20

Tell me your management of suspected DKA?

Answer 20

1. Secure airway, consider Ng tube to avoid aspiration (ABCDE- resuscitation)

Obtain IV access x 2; take blood and blood gas- look for bgl, ph, blood/urinary ketones + UEC, wcc

If bgl greater than 11.1 mmol/l, ph low, ketones present; biochemical dx of DKA.

2. Supportive management eg 02, cardiac monitoring if required
3. Determine level of dehydration; if moderate/severe; commence fluid bolus therapy of 0.9% normal saline 10ml/kg and reassess. If mild, may not need fluid bolus.
4. IV insulin + potassium (check k+ levels first prior to replacing)
5. Ongoing monitoring- blood gas, UEC blood glucose

Watch out for hypoglycaemia and hyponatremia

switch to SC insulin when appropriate and change fluids to normal saline + 5% dextrose when BGL reaches between 12-15mmol/l

Question 21

what is the dose of adrenaline for resuscitation of a paediatric patient?

Answer 21

10mcg/kg

Question 22

what are the hand techniques used when administering CPR in a neonate, young child and older child

Answer 22

With large children use the “heel” of one hand with the other superimposed.

For small children use the heel of one hand

For infants use two fingers.

For newborn infants the best technique is a two-handed hold in which both thumbs compress the sternum.

Question 23

what are the complications of untreated nephrotic syndrome?

Answer 23

hypovolemia

infection

thrombosis

Question 24

how do we manage confirmed first presentation of nephrotic syndrome in a child?

Answer 24

1. admit to hospital
2. oedema management- frusemide, fluid restriction etc
3. prophylactic antibiotics
4. prednisolone based on BSA
5. family education regarding relapses and immunisations whilst on steroid therapy
6. review with nephrology

Question 25

in prednisolone resistant cases of nephrotic syndrome, what medication might you try?

Answer 25

cyclophosphamide

Question 26

You (as a community/rural doctor) refer a child to the RCH and they require acute medical ICU management during their transport. what transport service do you call?

Answer 26

PIPER

paediatric infant perinatal emergency retrieval

Question 27

what antibiotics do we give for necrotitising fasciitis?

Answer 27

flucloxacillin

clindamycin

Question 28

what antibiotics do we use for a child with meningitic symptoms and possible encephalitis? lets say the child is older than 2 yrs old.

Answer 28

ceftriaxone + dexamethasone

+ ACICLOVIR

Question 29

which kids need to be medically assessed in the case of suspected paracetamol overdose?

Answer 29

• Acute ingestion of > 200mg/kg
• Ingestion of unknown quantity
• Repeated supratherapeutic ingestion of > 100mg/kg/day

Question 30

what are some clinical features of paracetamol toxicity in a child?

Answer 30

RUQ pain or tenderness, nausea, vomiting

Question 31

what ix should we order for a child who we suspect has had a paracetamol overdose?

Answer 31

LFTs
UEC- can cause acute kidney injury
serum paracetamol levels!- determines whether NAC should be given

Question 32

what key question on history should be asked in the case of a suspected acute paracetamol overdose in a child?

Answer 32

how long ago did the child ingest the paracetamol?

if > 8 hrs, warrants n-acetylcysteine

Question 33

a child comes into ED fitting > 5mins and it does NOT appear to be a febrile convulsion. What is your line of management?

Answer 33

DRSABCD- call for help

1. Support airway and breathing, provide O2 with mask
2. Gain IV access- check electrolytes and BSL (bedside finger prick)
3. If low BSL–> manage as for hypoglycaemia
4. Give buccal benzodiazepine like midazolam or diazepam
5. repeat benzo after 5mins if still fitting
6. for refractive convulsions, give phenytoin
7. senior assistance and intubation may be required in the case the above approach does not work

Question 34

what are the clinical features of epiglottitis?

Answer 34

Absent cough with low pitched expiratory stridor (often snoring) and drooling suggests epiglottitis.

Question 35

what is your management of a child with acute abdo pain?

Answer 35

ABC
Early referral of patients with possible diagnoses requiring surgical management.
Fluid resuscitation may be required (initial bolus 20ml/kg normal saline)
Establish and maintain intravenous access in sick children.
Measure electrolytes and blood sugar if the patient appears dehydrated
Keep patients fasting if surgical cause suspected
Provide adequate analgesia – iv morphine may be required or intranasal fentanyl as initial analgesia in severe pain (see Analgesia and sedation)
Consider a nasogastric tube if bowel obstruction suspected
Consider IV antibiotics in surgical causes (discuss with surgeon first)
Other investigations and management will be guided by clinical findings

Question 36

tell me the clinical presentation of intussuception

Answer 36

The child appears to have intermittent pain, which is colicky, severe and may be associated with the child drawing up the legs.
• Episodes typically occur 2‐3 times/hour and may increase over the next 12‐24 hours.
• During these episodes of crying the child may look pale. Note that many other causes of infant crying are associated with facial
redness rather than pallor.
• Pallor and lethargy may be the predominant presenting signs, but may be persistent rather than episodic, and in some the
crying episodes may not be very vigorous.
• Vomiting is usually a prominent feature (but bile stained vomiting is a late sign).
• Bowel motions may contain blood and/or mucus. The classic red currant jelly stool is a late sign.

Question 37

describe key ix and mx considerations for suspected intussuception?

Answer 37

AXR looking for bowel obstruction/perforation
U/S- target sign- diagnostic

manage fluid status- resus as required
NGT tube to drain free fluid
IV cefazolin/metronidazole
Air enema reduction–> diagnostic and therapeutic

Question 38

what is your management of bilious vomiting in a neonate?

Answer 38

1. Admit the infant
2. Call the neonatologist and contact paed surgical registrar
3. Do your ABC. Keep airway patent, supply O2 mask and establish IV access
4. Check BSL and correct glucose if required.
5. Keep baby warm
6. Take bloods: FBE, UEC, LFTs, ABG, cross match, coags
7. Order AXR erect and supine + upper GI contrast study
8. Insert oral gastric tube and commence IV fluids.
9. Keep nil by mouth and correct any abnormal electolytes.
10. Administer IV antibiotics if required.
    Keep the parents updated and depending on the pathology (e.g. malrotation) advise them of the treatment options/plan.