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Paediatrics > Spotting the sick child > Flashcards

Spotting the sick child Flashcards

1
Q

What are the most common viruses and bacteria to cause difficulty breathing in children?

A

-Strep pneumoniae
-Respiratory synctial virus
-Mycoplasma
-Human metapneumovirus
-Pertussis
-Influenza/parainfluenza

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2
Q

What are the 4 commonest causes of breathlessness in children?

A
  1. Asthma
  2. Bronchiolitis
  3. Pneumonia
  4. Croup
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3
Q

What is the pathogenesis of asthma?

A

Asthma is caused by hyper-reactive airways. The bronchi constrict and secrete mucus. The narrowed airways produce the sound we know as wheezing

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4
Q

What are the symptoms of asthma?

A

-Breathlessness
-Coughing
-Wheezing (high pitched sound heard on expiration)
-Expiration phase tends to be prolonged

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5
Q

What are the common triggers for an exacerbation of asthma?

A

-Cigarette smoke
-Exercise
-Excitement
-Dust
-Pollen
-Allergies to animals

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6
Q

Are viral or bacterial infections more commonly present during an exacerbation of asthma?

A

Viruses. Bacteria are not normally present so antibiotics aren’t usually needed. However, a virus such as a cold can bring on a few days of wheeziness (viral-induced wheeze) which may not necessarily be asthma.

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7
Q

What is Croup? What are the main characteristics?

A

A viral infection of the upper airway, which causes airway obstruction and difficulty in breathing. It is commonest in toddlers. The inflammation of the airway causes a characteristic barking cough and a hoarse voice. Turbulent air flow through the narrowed airway causes stridor, which may be inspiratory or expiratory.
Other typical signs include: Intercostal recession, subcostal recession, sternal recession and tracheal tug

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8
Q

Which steroids does croup respond well to?

A

-Oral Dexamethasone
-Prednisolone
-Nebulised budesonide

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9
Q

Which immediate effect treatment can be used in severe croup?

A

Adrenaline nebuliser. Buys time by shrinking the inflamed airway while the steroids begin to work.

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10
Q

Which ages does bronchiolitis mainly affect?

A

Infants aged 1 month to 1 year

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11
Q

What are the symptoms of bronchiolitis?

A

-SOB
-Wheezing
-Wheezy cough
-Runny nose
-Mild temperature
-Reduced feeding - when the infant becomes tired

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12
Q

What is the main virus to cause bronchiolitis and how does it affect the airways?

A

Respiratory synctial virus.
It affects the lower airways causing secretions. The infant will therefore have a wet sounding cough and will sound wheezy.

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13
Q

What are the signs of a bacterial pneumonia?

A

Children with bacterial pneumonia will appear more unwell and lethargic than with common viral respiratory infections, with a temperature typically above 38.5 degrees, and they often refuse food and drink. There is often noisy breathing and signs of respiratory distress (tachypnoeic, accessory muscle use and subcostal recession). Raised respiratory rate is the most important discriminatory sign.

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14
Q

What is status asthmaticus?

A

Acute severe asthma attack

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15
Q

What are the commonest causes of feverish illness in children?

A

-UTI
-Pneumonia
-Skin/soft tissue infection
-Meningitis
-Otitis media
-Tonsillitis
-Surgical causes
-Septic arthritis/osteomyelitis

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16
Q

What happens to the body as a localised infection spreads and starts to cause septicaemia?

A

When bacteria multiply in the bloodstream they release poisons such as endotoxin (eg meningococcal septicaemia involves release of the endotoxin that causes the purple rash). The body’s own inflammatory response causes effects such as leaky blood vessels, poor contraction of the heart and can cause the lungs or other organs to fail. The patient loses fluid from the blood stream and develops circulatory failure and shock.

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17
Q

In an infection, why is it important to check capillary refill time and temperature of the hands and feet?

A

In the early stages, children compensate very well by an autonomic response, which vasoconstricts in the peripheries. This makes sure that the vital organs such as the brain and kidneys, still receive an adequate blood supply. This is called peripheral shutdown.

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18
Q

Which blood tests can help to determine the severity of an infection?

A

Venous blood gases and white cell counts.
Lactic acid is released into the circulation through anaerobic metabolism when peripheral tissues are underperfused. There will be metabolic acidosis and a high lactate. A base excess of more than -3 or a lactate of more than 3 are significant in this situation. The acidosis causes a child to breathe faster in order to normalise the blood pH. This is why measuring the respiratory rate is very important.

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19
Q

What is kawasaki disease? How does it present?

A

A disease of childhood, most common in the under 2s. Children present with fever (usually more than 39 degrees) for several days and may have rash (usually maculopapular), conjunctivitis (red eyes), mucous membrane changes, cervical lymphadenopathy (usually on one side), extremity changes such as erythema, swelling or desquamation (peeling of skin). There can be serious complications involving the heart and coronary arteries.

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20
Q

What are the commonest causes of meningitis in neonates, infants and children in the UK?

A

Neonatal period:
-E. coli
-Group B strep

Neonate - 2 years:
-Haemophilus influenzae B
-Pneumococcus
-Meningococcus (neisseria meningitidis)

All ages:
-Viral infections
-TB
-Meningococcus B

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20
Q

What are the signs and symptoms of meningitis?

A

-Fever
-Vomiting
-Headache
-Bulging fontanelle (infants)
-Stiff neck
-Photophobia
-Sleepy/vacant/difficult to wake
-Confused/delirious
-Seizures

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21
Q

What are the signs and symptoms of meningococcal septicaemia?

A

-Fever (or hypothermia in small infants)
-Rigors
-Rash (purple)
-Tachypnoea
-Tachycardia
-Pale or mottled skin
-Cold hands and feet
-Sleepy/vacant/difficult to wake
-Confused/delirious
-Limb/joint/muscle pain

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22
Q

What are macular and papular rashes? What might they be a sign of?

A

Macular: splotchy and under the skin, so you can’t feel it
Papular: Also splotchy with raised area.

The two often happen together and are often described as maculo-papular. This happens in mild viral rashes, in rubella, measles and also in Kawasaki disease.

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23
Q

What might vesicular or pustular rashes be a sign of?

A

Vesicular (little blisters) - chickenpox, herpes simplex and shingles

Pustular (pus-filled blisters) - Streptococcus or staphylococcus infection

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24
Q

What are petechiae and purpura?

A

Petechiae - little pink or purple dots a millimetre or less in size, and are flat.

Purpura - Purple areas 2mm or bigger that mean that blood has leaked from the vessels.

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25
Q

What causes meningococcal sepsis? What is the characteristic rash?

A

The organism Neisseria meningitidis secretes a toxin which causes damage to blood vessels. The blood leaks into the skin and causes the characteristic non-blanching rash. The appearance of the rash is more like a bruise than pinkness of the skin.

26
Q

What is urticaria?

A

An inflamed, itchy, bumpy rash usually all over the body. It is caused by allergy, and may occur in anaphylaxis. It can come up and go back down quite quickly.

27
Q

What is eczema? What are the key features?

A

Skin condition causing dry, itchy skin. The reaction as part of an allergy is called allergic dermatitis. Eczema is usually around the neck, elbows, knees and armpits and face. It can look quite inflamed and secondary bacterial infection sometimes occurs, which tends to make it weepy with scabs.

28
Q

What is seborrhoeic dermatitis?

A

A variation of eczema. This is bumpy and usually happens on dry skin. Babies with this condition may have cradle cap.

29
Q

What is Neisseria Meningitidis?

A

A bacterium that is carried in the nose of a lot of people, but in some people it spreads through the bloodstream, leading to meningitis or meningococcal sepsis. It is most common in children under two and those aged 16-21.

It is a gram-negative diplococcus

30
Q

How does meningococcal sepsis present?

A

The sepsis presents like any serious bacterial infection, although it may cause joint pain. The rash can be non-specific, petechial or purpuric. The petechiae may blanch initially. As the disease progresses and the child becomes visibly unwell, the rash becomes non-blanching or obvious areas of haemorrhage occur. This is due to the bacterium releasing a toxin, which makes the blood vessels permeable.

31
Q

What is Stevens-Johnson syndrome?

A

A disease which causes a rash and also causes the mouth and other mucous membranes to blister. The rash has a very characteristic appearance of circles called target lesions. This is because they look like a red target with a pale centre.

(Cases where there is just the rash and no mucous membrane involvement are called erythema multiforme)

Children tend to be miserable and often need hospital admission if they can’t drink. The disease may become quite severe

32
Q

What causes toxic-shock syndrome? How does it present?

A

It is caused by a toxin secreting bacteria, either streptococcus or sometimes staphylococcus. It may occur 2-3 days after a minor burn.
The child presents with fever, diarrhoea, appears unwell and has an erythematous rash. Just like in meningococcal septicaemia, the child may become critically unwell in a few hours, and needs antibiotics as soon as the diagnosis is suspected

33
Q

What is Henoch-Schonlein Purpura? What are the characteristic features?

A

An immune disease which causes bleeding into the skin. It causes a similar rash to meningococcal septicaemia, however the child is generally well. The rash tends to be worse on the back of the legs and the buttocks. Bleeding also occurs in the wall of the intestine, which causes pain and can even cause intussusception. Bleeding can occur in the joints and cause quite severe joint pain.

34
Q

What is the big risk with Henoch-Schonlein purpura? Why should it be diagnosed early?

A

It can cause kidney disease. BP should be checked for this reason. Urinalysis should be repeated frequently for the first few weeks.

35
Q

What is idiopathic thrombocytopaenic purpura? (ITP)

A

An immune disease which affects the platelets and therefore the blood clotting. It causes petechiae in the skin. The child will be completely well other than the rash. It is important to diagnose it with a full blood count and refer the child to a paediatrician, in case they need treatment with steroids.

36
Q

What are the common causes of fit-like episodes?

A

None-seizure events:
-Faints: may cause a few jerks and be mistaken for a true fit.
-Cardiac syncope (vasovagal faint or drop in BP due to arrythmia): there can be jerks as they faint as well as incontinence. The difference is in the recovery phase which is swift, the patient is back to normal in a minute or so. These usually happen from aged 7 onwards.

True seizures:
-Febrile convulsions: Usually generalised, tonic-clonic seizures that happen out of the blue with a mild infection. Usually aged 1-3 years old.
-Primary epilepsy
-Secondary epilepsy (cerebral palsy, structural brain lesions, syndromes)
-Reflex anoxic seizures (seizures caused by periods of asystole)
-Alcohol and drugs (intoxication or withdrawal)
-Head injury (including non-accidental injury)
-Infections - meningitis/encephalitis
-Metabolic - hypoglycaemia, hyponatraemia. hypocalcaemia

37
Q

What happens in the post-ictal phase?

A

Most children are sleepy for 10 mins to an hour. During this time they have memory loss. Once they come around they usually have a headache, so are often irritable.

38
Q

What are the two types of fit?

A
  1. Generalised: the child is unaware of their surroundings
  2. Focal: the child is awake and the fit is affecting a part of the body. If the child is aware of the fit they are called a partial seizure. Focal fits are unusual unless a child is known to have epilepsy or an underlying problem with the brain
39
Q

What are the key features of a generalised tonic-clonic seizure?

A

The child becomes unconscious and stiffens, usually this is followed by full body jerking. (grand mal). During the fit, the eyes are usually rolled upwards, the jaw and fists clench, some grunting noises may be heard and the child may be red or a bit blue in the face. There may be salivation and sweating.

40
Q

What is an absence seizure?

A

When a child stops what they are doing and freezes for a few seconds. It often happens in children with other kinds of fits as well.

41
Q

How is a seizure managed?

A

First give oxygen straight away (nasopharyngeal airway as others are difficult to insert if the jaw is clamped shut). Get intravenous access to give bloods (either APLS or EPLS guidelines - first line management is midazolam, lorazepam, diazepam). Take a blood glucose.

42
Q

What 2 things should you investigate after a seizure?

A
  1. Serious complications of the fit
    -Airway obstruction
    -Respiratory depression
    -Circulation: dehydration, sepsis.
    -GCS
    -Hypoglycaemia (can cause brain damage)
  2. The cause of the fit
    -Neurological exam
    -ENT exam
    -Glucose (hypoglycaemia is an important cause of fits)
43
Q

How do fits look different in infants compared with older children?

A

The limbs go into an abnormal posture, babies go stiff and their eyes deviate. The fit is quite short. Some babies just go floppy for a few seconds. The jerking of the limbs and body is less violent and therefore more subtle than older children. The eyes may stay open rather than being closed or rolling upwards. Towards the end of the fit, there may be a myoclonic jerk, then lip smacking. Fits at this age are not usually innocent and require full investigation

44
Q

How can aspiration occur during a seizure?

A

It is possible for stomach contents to be inhaled into the lungs. Usually vomit has been seen, but not always. It is common for children to vomit in the post-ictal phase which is why it is important to keep them in the recovery position. In the early stages the only sign may be slightly reduced SaO2 readings after a fit. there may also be high resp rate or respiratory distress.

45
Q

What is Status epilepticus?

A

When a fit lasts more than 30 minutes, or if there is incomplete recovery between fits. There is a risk of serious complications, brain damage and even death. Prompt treatment is needed before the fit gets to 30 minutes (give oxygen and benzodiazepines).

46
Q

What is the most common cause of dehydration in children?

A

Gastroenteritis. Commonly caused by viruses such as rotavirus.

47
Q

What are the common causes of vomiting in childhood?

A

Infants < 6 months:
-Posseting
-Feeding problems
-Pyloric stenosis
-Gastro-oesophageal reflux

0-5 years:
-URTI/coughing
-Intussusception
-UTI

0-12 years:
-Gastroenteritis
-Meningitis
-Migraine
-Brain tumour

48
Q

What is an oral challenge?

A

Giving children oral fluids very little and very often

49
Q

What might blood in the stools be a sign of?

A

Salmonella
Shigella
Intussusception

50
Q

What is the key cause of jittering in babies?

A

Hypoglycaemia

51
Q

What are the signs of dehydration?

A

-Sunken eyes: ask the parents or look at recent photos
-Sunken fontanelle in an infant ( compared to normal)
-Dry mucous membranes - look at tongue
-Mottled skin and cool extremities (poor perfusion due to vasoconstriction
-Skin turgor: if loose when pinched then is dehydration
-Prolonged capillary refill time
-Increased heart rate and poor pulse volume
-Hypotension
-Weight loss
-Oliguria

Children with mild dehydration will have only one or two of these signs. Those with more may have moderate or severe dehydration

52
Q

What is pyloric stenosis? How is it managed?

A

A diagnosis specific to babies in the 4-6 week age group. It is a muscular swelling at the outlet of the stomach, which stops food going into the duodenum. This causes distension of the stomach and the baby suddenly vomits either towards the end of or just after a feed. The vomiting is forceful - projectile vomiting.
Babies with pyloric stenosis get dehydrated quite quickly, and need an urgent operation to release the constriction. Diagnosis depends on finding typical changes on a venous blood gas sample and on ultrasound.

53
Q

What is the severe kind of dehydration seen in babies? How does it present?

A

Hypernatraemic dehydration.

Babies have immature kidneys, and if they are dehydrated through not feeding or through diarrhoea, the kidneys are not able to compensate by retaining water in the right proportions. There is then an imbalance between sodium and water, which results in high blood sodium concentration. The sodium level may be very high, such as 160.

It is most commonly seen in the first couple of weeks of life when breastfeeding has been difficult to establish. It can also be seen in bottle fed babies if the feeds have been made up incorrectly, or in babies with profuse watery diarrhoea. The high sodium levels in the blood cause the baby to be drowsy and not wake up to feed. The high sodium prevents the fontanelle and eyes from appearing dehydrated, so it is very easy to miss the diagnosis. It may well present as a baby with difficulty in feeding

54
Q

What are the give away signs of diabetic ketoacidosis?

A

-Dehydration
-High respiratory rate: caused by acidosis

55
Q

What are the main causes of abdominal pain?

A

Abdominal conditions:
-Colic
-Intussusception
-Mesenteric adenitis
-Constipation
-Inflammatory bowel disease
-Coeliac disease
-Bowel obstruction
-Incarcerated hernia
-Malrotation
-Meckel’s diverticulum

Extra-abdominal conditions:
-Migraine
-DKA
-Infection elsewhere
-Pneumonia
-UTI
-Stress

Malignancy:
-Neuroblastoma
-Wilms tumour (nephroblastoma)

-Testicular torsion

56
Q

What are the main causes of acute abdominal pain?

A

-UTI
-DKA
-Surgical problems: intussusception, bowel obstruction, appendicitis, malrotation of the intestines and meckel’s diverticulum

57
Q

What are the main causes of chronic abdominal pain?

A

-Constipation
-IBD
-Malignancy

58
Q

What is peritonitis? How does it present?

A

Severe inflammation within the peritoneal cavity of the abdomen which usually means that surgery is needed. There will be widespread guarding or involuntary tensing of the abdominal muscles when you palpate the abdomen. At this stage there are often signs of dehydration or sepsis. The commonest cause in childhood is a perforated appendix.

59
Q

What is intussusception? What is it caused by and how does it present?

A

Invagination of the intestine into itself. Usually affects infants and toddlers. It can be associated with extra-abdominal infections (eg tonsillitis or an ear infection) because these make lymph nodes (called peyer’s patches) in the bowel wall swell, these act as a lead point for the bowel to fold on.

The pain is characteristically colicky, and the child will settle in-between bouts of this pain. A mass may be felt in the abdomen, usually on the right hand side

60
Q

What does the vomiting of bile (bilious vomiting) suggest?

A

Vomiting bile means there is an intestinal obstruction so is a very important symptom. If parents say the vomit had a green colour, you need to be sure that there are no signs of obstruction before you attribute it to an empty stomach.

Bilious vomiting is intestinal obstruction until proven otherwise.

61
Q

In a head injury, what are the indications for a scan?

A

-Vomiting
-Drowsiness
-Loss of consciousness

62
Q

What are unequal pupils associated with?

A

An intracranial bleed

63
Q

What does a boggy swelling on the head suggest?

A

An underlying skull fracture

Paediatrics (6 decks)

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