30 - Emergency Paediatrics 2 Flashcards by Leah Ashton

What is the definition of a brief resolved unexplained event (BRUE)? (formerly known as ALTE)

An event occurring in an infant younger than 1 year when the caregiver reports a sudden, brief (<1 minute) and now resolved episode of ≥1 of:

Change in colour
Apnea
Marked change in tone (hyper or hypotonia)
Altered level of responsiveness

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What is the epidemiology and risk factors of BRUE?

Epidemiology

1% of emergency presentations of infants less than a year old
M>F
Mean age 8 weeks

Risk Factors

Infants < 2 months old
Patients who were premature and have had multiple ALTEs

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What is the pathophysiology of BRUE?

GORD (50%)
Idiopathic (50%)

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What questions do you need to ask a parent when there is a BRUE episode?

Timing
Relation to feeding
Previous episodes
How does baby sleep?
Any recent infection or family member unwell?
PMHx (BIND)
FHx of any cardiac or metabolism issues
SHx and risks of this being NAI

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What examination should you do for a child with BRUE?

General: Vital signs, BM, Growth (weight and head circumference), dysmorphic features, any bruises or marks suspicious of NAI

Respiratory including ENT: any signs of URTI or LRTI

CVS: femoral pulse for coarctation of aorta, any murmurs

Abdominal: Tenderness with a sausage shaped mass, groin for hernias

Neurological: pupil responses, limb tone, power, fundoscopy if suspect NAI

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To guide investigations and management of BRUE, children are stratified as high risk or low risk. What are some low risk features?

Age > 2months
Gestational age >32 weeks
No previous BRUE
Event lasted < 1 minute
No CPR required
No concerning features in history or examination

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What investigations are done for a high risk and low risk patient?

Low Risk

ECG – exclude channelopathies, WPW or cardiomyopathy. Calculate QTc
Consider pernasal swab for pertussis

High Risk

ECG and pernasal swab for pertussis
CXR
Blood gas - may have metabolic acidosis if inborn error of metabolism
FBC, Film, U+Es, CRP, bone profile, glucose
Blood culture, Urine culture, LP if suspect sepsis/meningitis

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What investigations need to be done if you suspect an inborn error of metabolism?

Serum amino acids and ammonia samples (on ice)

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How are BRUE patients managed?

Parental reassurance and period of observation of child

Low Risk

Safety netting advice for what to do if future episodes occur
Formal Basic Life Support (BLS) training should be offered
Follow up in primary care
Observe feed if infant

High Risk

Refer to paeds for admission and investigations
Overnight oxygen saturation monitoring
If stable discharge home with same advice as above

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Transient hypoglycaemia (<2.6mmol/L) in the first 24 hours after birth is common and normal as babies can utilise lactate and ketones.

What are some causes of prolonged neonatal hypoglycaemia?

Preterm < 37 weeks
Maternal diabetes mellitus
IUGR
Hypothermia
Neonatal sepsis
Inborn errors of metabolism
Beckwith-Wiedemann syndrome

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What are some signs of hypoglycaemia in neonates and how is it managed?

Asymptomatic
Irritable
Tachypnoea
Pallor
Poor feeding
Weak cry
Drowsy
Hypotonia
Seizures
Apnea
Hypothermia

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Hypoglycaemia is define as <2.6mmol/L in babies aged <6 months and <3mmol/L if aged >6 months. What investigations need to be done when a child has hypoglycaemia?

Need to find a cause and bloods have to be taken at time of hypoglycaemia

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After a hypo screen is taken, how is hypoglycaemia corrected in this emergency?

IMPORTANT CARD, LOOK AT IMAGE

Monitor BM hourly until stable, always take BM 10-15 minutes after intervention

If child is conscious and not vomiting

PO glucose dextrogel 1⁄2 tube (5g) for infants <6 months and 1 tube if >6 months
In an older child give oral glucose 10–20 g
Followed by snack of starchy carbohydrates or a milk feed in infants

Altered consciousness

2 ml/kg 10% glucose/0.9% NaCl as IV bolus followed by infusion containing 10% glucose
If no IV access stat glucagon IM: 0.5mg for patients < 8 yrs age or <25 kg, 1 mg for patients > 8 yrs age or >25 kg. Followed by IV or IO infusion of glucose

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How do you calculate glucose infusion rate and what does this tell you?

Most children will be normoglycemia on 5-8 mg/kg/min

If <12 think hyperinsulinaemia so refer urgently to endocrinology

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How does malnutrition present in children?

not growing or putting on weight at the expected rate (faltering growth)
changes in behaviour, such as being unusually irritable, slow or anxious
low energy levels and tiring more easily than other children

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What are causes of malnutrition in children?

Poverty
Eating disorder
CHD
Cerebral palsy
Diarrhoea
Coeliac’s
Cystic fibrosis

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How is malnutrition in children managed?

Eating foods high in energy and nutrients
Support for families
Treatment for any underlying medical conditions
Vitamin and mineral supplements
Regular weight and height monitoring

Severely malnourished children need to be fed and rehydrated in hospital and gradually being reintroducing food

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What is the treatment for the following overdoses?

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What is the treatment for the following toxins/overdoses?

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What is the treatment for the following toxins/overdoses?

Give oxygen for cyanide poisoning to all children

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What are the most common causes of overdose in children?

Paracetamol
Ibuprofen
Aspirin
Iron preparations
Cough medicine
COCP
Asthma medication

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What databases should be use to guide management of overdose?

TOXBASE
National Poisons Information Service

Always try to establish what poison, how much, over what period of time

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What are some common signs of OD in children that need managing?

OD is treated supportively majority of the time

Respiratory depression
Hypotension
Arrhythmias
Hypo/hyperthermia
Convulsions (give benzos)

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When should you not use activated charcoal for OD?

>1 hour since ingestion
Petroleum distillates
Alcohols
Cyanides
Iron and lithium salts

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Haemodialysis and Urinary alkalisation are two methods of elimination that can be used in OD. For what substances are they used?

* **Haemodialysis**: ethylene glycol, lithium, methanol, phenobarbital, salicylates, and sodium valproate * **Alkalinisation of the urine:** salicylates

How is alcohol intoxication in children managed?

**Features:** ataxia, dysarthria, nystagmus, and drowsiness, which may progress to coma, with hypotension and acidosis Maintain a clear airway, reduce risk of aspiration of gastric contents, check BM and give glucose if needed DO NOT GASTRIC ASPIRATE

How is aspirin poisoning managed?

* Activated charcoal * Fluid replacement * IV sodium bicarbonate * Haemodialysis

When does paracetamol OD present in children and how may it present?

3-4 days post OD if \>75mg/kg * Nausea and vomiting * RUQ pain/tenderness * Encephalopathy * Coma * Coagulopathy

What are some important blood tests in paracetamol OD?

* Serum paracetamol levels at 4 hours (for graph) * LFTs * U+Es * FBC * Glucose * INR and clotting * Blood gas

Children are given activated charcoal if presenting within an hour of paracetamol OD. Which children are given NAC?

* Plasma-paracetamol concentration falls on or above the treatment line * Present within 8 hours of ingestion of more than 150 mg/kg * Present more than 24 hours of ingestion of an overdose if they are clearly jaundiced or have hepatic tenderness, their ALT is above the upper limit of normal, their INR is greater than 1.3, or the paracetamol concentration is detectable

What are some side effects of NAC and how are they managed?

What are the two regimes for NAC?

* Standard 21-hour IV regimen * Modified 12-hour regimen For the standard 21-hour regimen, [acetylcysteine](https://bnfc.nice.org.uk/drug/acetylcysteine.html) is given in a total dose that is divided into 3 consecutive intravenous infusions over a total of 21 hours

What are some signs of iron poisoning in children?

* Nausea and vomiting * Abdominal pain * Diarrhoea, haematemesis * Rectal bleeding * Hypotension * Coma, shock, and metabolic acidosis indicate severe poisoning.

Iron poisoning is often accidental in children. How is it treated?

**IV Desferrioxamine** to chelate iron Take serum-iron concentration and calculate dose from this

What is the most important management for deliberate OD in children once they are stable?

CAHMS REFERRAL

What are some signs that show there is effort of breathing?

What are some causes of acute abdominal pain in children?

TRY USE SURGICAL SIEVE e.g surgical, infection, endocrine, trauma * UTI * Intussuseption * Appendicitis * Torsion * Mesenteric adenitis * Pneumonia * Hernia * Volvulus * Constipation * Gastroenteritis * DKA * NAI/Trauma * Sickle cell crisis * Ectopic

What are some differentials for acute joint pain?

* Fracture * Dislocastion * Septic arthritis * Reactive arthritis * SUFE * Pethe's disease * Osteomyelitis * Malignancy * HSP

What are some reasons a well baby may cry?

* Hunger * A dirty or wet nappy * Tiredness * Wanting a cuddle * Wind * Too hot or too cold * Boredom * Overstimulation

Crying peaks around 6-8 weeks. What are some tips to give parents when they have a baby who is excessively crying?

* Take parents' concerns seriously * Involve health visitor * Singing, rocking, going for a drive * Encourage help from extended family * Seek support at CrySis * If not coping, admit to a parenting centre or hospital

What type of crying is a red flag in a feverish child?

Weak High Pitched Continuous

What are some causes of inconsolable crying in children? (image important)

* Colic * CMPA * Intussusception * Sepsis * Meningitis * GORD

What is the Children's coma scale?

**Use if less than 4 years old,** if over 4 use GCS **_Best Motor Response_** Score best response of any limb * *6** **Carrying out a request/** Moves to your request * *5** **Localizing response to pain:** Put pressure on the patient’s finger nail bed * *4** **Withdraws to pain:** Pulls limb away from painful stimulus. * *3** **Flexor response to pain:** indicative of damage to cerebral hemispheres, thalamus, internal capsule or midbrain) * *2** **Extensor posturing to pain:** brainstem damage * *1** **No response to pain** **_Best Verbal Response_** **5** **Orientated:** to sounds, fixes and follows objects. **4** **Crying but consolable** (or interaction odd/inappropriate) **3** **Inconsistently consolable** (or moaning) **2** **Inconsolable crying** (or irritable) **1** **No response** **_Eye Opening_** * *4** **Spontaneous** * *3 R****esponse to speech** * *2 R****esponse to pain** * *1** **No eye opening**

What are some causes of decrease levels of consciousness in children?

Think respiratory, circulatory or CNS failure * DKA * Meningitis * Seizures * Hypothermia * Hypoglycaemia * Sepsis * Shock * Hypoxaemia

What monitoring should be done for children with decreased levels of consciousness?

GCS\<8 then intubate

What are some causes of vomiting in children?

What are some pathological causes of poor feeding in neonates?

* **Sepsis** * **Meningitis** * **Craniofacial abnormalities** e.g cleft pallate, trisomy 21 * **Pyloric stenosis** * **CHD** e.g Tet of Fallot * **LRTI** e.g bronchiolitis * **Hypothyroidism**

What are some causes of a limping child?

* Transient Synovitis * SUFE * Developmental dysplasia * Septic arthritis * JIA * Sprain * Trauma

What are some important things to consider when a child is limping?

* Age * Systemic symptoms * Fever

What are some causes of peripheral oedema in children?

Localised or Non-localised * Nephrotic Syndrome * Congestive Heart Failure due to CHD * Cirrhosis * Lymphoedema * Angioedema * Insect bite

How is peripheral oedema in children managed?

* Diuretics * IV albumin * Salt restriction

What are some causes of pneumothorax in children?

* **Primary Spontaneous** * **Secondary Spontaneous:** Asthma, Cystic Fibrosis, EDS * **Trauma:** CPAP/Artificial ventilation, chest wall trauma, foreign body aspiration, birth trauma * **Babies**: RDS, Meconium aspiration, Prematurity