Systemic inflammatory response syndrome = generalised inflammatory response, defined by the presence of ≥2 criteria (abnormal temperature or WCC must be one of the criteria): Abnormal core temperature (\ 38.5°C) Abnormal HR (\>2 S.D. above normal for age, or less than 10th centile for age if child aged \ 2 S.D. above normal for age, or mechanical ventilation for acute lung disease) Abnormal WCC in circulating blood (above or below normal range for age, or \>10% immature cells)

Emergencies Flashcards by Kishan P

Define Sepsis.

Systemic inflammatory response syndrome = generalised inflammatory response, defined by the presence of ≥2 criteria (abnormal temperature or WCC must be one of the criteria):
- Abnormal core temperature (<36 or >38.5°C)
- Abnormal HR (>2 S.D. above normal for age, or less than 10^th centile for age if child aged < 1 years)
- Raised RR (>2 S.D. above normal for age, or mechanical ventilation for acute lung disease)
- Abnormal WCC in circulating blood (above or below normal range for age, or >10% immature cells)

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What are the red flags for sepsis in children?

Hypotension
Blood lactate >2mmol/L
Prolonged capillary refill >5 seconds
Pale/mottled or non-blanching (purpuric) rash
Oxygen needed to maintain saturations >92%
RR >60 min-1 or >5 below normal, or grunting
AVPU = V, P or U
Abnormal behaviour
- Excessively dry nappies
- Lack of response to social cues
- Significantly decreased activity
- Weak
- High-pitched or continuous cry

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What defines Sepsis, Severe Sepsis or Septic Shock?

Sepsis = SIRS in the presence of infection
Severe sepsis = sepsis in presence of CV dysfunction, respiratory distress syndrome, or dysfunction of ≥2 organs
Septic shock = sepsis with CV dysfunction persisting after at least 40 mL/kg of fluid resuscitation in one hour

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What are the common causative organisms of sepsis in children?

Early onset neonatal = GBS, Escherichia coli, L. monocytogenes
Late onset neonatal = Coagulase-negative Staphylococcus
- i.e. Staphylococcus epidermidis
Other causative organisms:
- Staphylococcus aureus (Coagulase +ve)
- Non-pyogenic streptococci
- Streptococcus pneumoniae
- Neisseria meningitidis

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What are the appropriate investigations for suspected sepsis in children?

Clinical suspicion - diagnosis cannot be delayed
Sepsis 6
- Blood cultures
- Urine output
- Fluids
- Antibiotics
- Lactate
- Oxygen
LP in the following
- <1m old
- 1-3m who appear unwell
- 1-3m with WCC <5 or >15 x109/L
Bloods
- Clotting (as DIC can feature in sepsis)
- VBG (including glucose and lactate)
- Blood culture
- FBC
- CRP (N.B. takes 12-24hrs to rise)
- U&Es and creatinine
Imaging - CXR
Urine dipstick on MSU

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What is the management of meningococcal sepsis in children?

Sepsis 6 within 1 hour + continuous monitoring
- Review by ST4 or above (<30 minutes) and then a consultant (<1 hour)
IV access
IV fluid resuscitation
20mL/kg 0.9% NaCl bolus
Antibiotics within 1hr → follow local guidelines:
- If meningococcal sepsis
  - IM benzylpenicillin + ambulance (GP)
  - IV cefotaxime (in hospital)

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What is the management of non-meningococcal sepsis in children?

Sepsis 6 within 1 hour + continuous monitoring
- Review by ST4 or above (<30 minutes) and then a consultant (<1 hour)
IV access
IV fluid resuscitation
20mL/kg 0.9% NaCl bolus
Antibiotics within 1hr → follow local guidelines
- Early onset <72 hours = GBS, L. monocytogenes, E. coli
  - benzylpenicillin / ampicillin + gentamicin
- Late onset >72 hours = CoNS (S. epidermidis)
  - ampicillin / vancomycin + gentamicin / cefotaxime
- >1 month
  - cefotaxime / ceftriaxone / piperacillin / meropenem

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What is the management of sepsis with necrotising enterocolitis in children?

Sepsis 6 within 1 hour + continuous monitoring
- Review by ST4 or above (<30 minutes) and then a consultant (<1 hour)
IV access
IV fluid resuscitation
20mL/kg 0.9% NaCl bolus
Antibiotics within 1hr → follow local guidelines:
- metronidazole - active against anaerobic bacteria

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What are the signs in cold shock?

CRT >2s
Reduced peripheral pulses
Cool mottled extremities
Narrow pulse pressure

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What are the signs in warm shock?

Flash CRT
Bounding peripheral pulses
Warm extremities
Wide pulse pressure

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What are the signs and symptoms of meningitis in a child?

Bulging fontanelle, hyperextension of neck and back
Headache
Photophobia
Neck stiffness
Fever
Kernig’s sign – pain on leg straightening
Brudzinski’s sign – supine neck flexion à knee/hip flexion
Lethargy
Altered consciousness/Drowsiness
Seizures
Non-blanching rash (80% of meningococcal)
HR starts high to compensate ischaemia in brain
- HR then drops as baroreceptors in heart sense high BP (from HR)
Raised ICP symptoms (late signs) = Cushing’s Triad:
- High BP
- Low HR
- Irregular RR

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What are the appropriate investigations for childhood meningitis?

Sepsis 6
LP
- CT head before LP if concerns of raised ICP
Blood culture
Bloods
- FBC, CRP, U&E and glucose
Coagulation profile
Further immunological analysis (complement deficiency) if >1 episode of meningococcal meningitis

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What are the causes of meningitis in children?

Neonatal - 3 months
- GBS
- E. coli and other coliforms
- Listeria monocytogenes
3 months - 6 years
- Neisseria meningitidis
- Strepococcus pneumoniae
- Haemophilus influenza
>6 years
- Neisseria meningitidis
- Strepococcus pneumoniae

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What is the management of childhood bacterial meningitis?

Antibiotics
- Child <3m old:
  - IV cefotaxime
  - IV amoxicillin / ampicillin
- Child >3m old:
  - IM benzylpenicillin, STAT
    - If pen allergy = moxifloxacin & vancomycin
  - IV ceftriaxone:
Steroids/Dexamethasone – if CSF shows
- Purulent CSF
- WBC >1,000/uL
- Raised CSF WCC + protein >1g/L
- Bacteria gram stain
- >1m old & H. influenzae
- NOT MENINGOCOCCAL
Mannitol - reduce ICP
IV saline sodium chloride 0.9%
Notify HPU
Treat contacts (ciprofloxacin) and offer further support

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What follow-up should be offered to children who had meningitis?

Review patient 4-6w after discharge to discuss long-term potential complications
- Hearing loss → audiological assessment
- Orthopaedic, skin, psychosocial complications
- Neurological/development problems
- Renal failure
Purpura fulminans = haemorrhagic skin necrosis from DIC → acute/fatal, thrombotic disorder, manifest as blood spots/bruising/discolouration of skin
- Needs FFP, debridement or amputation

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What is the management of viral meningitis?

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Discharge home - after tests to exclude bacterial causes
- With supportive therapy (i.e. fluids)
Safety net

What are the common causes of viral meningitis?

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Coxsackie Group B
Echovirus

What is the route of encephalitis infection?

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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
- Most common UK:
  - Enterovirus
  - Respiratory viruses (influenza)
  - Herpes
    - >70% mortality from untreated HSV encephalitis
- Other = HIV, chickenpox, bacteria & fungus (very rare), mosquitos, ticks, rabies

What are the signs and symptoms of encephalitis in children?

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Bulging fontanelle, hyperextension of neck and back
Headache
Photophobia
Neck stiffness
Fever
Kernig’s sign – pain on leg straightening
Brudzinski’s sign – supine neck flexion à knee/hip flexion
Lethargy
Altered consciousness/Drowsiness
Seizures
Non-blanching rash (80% of meningococcal)
HR starts high to compensate ischaemia in brain
- HR then drops as baroreceptors in heart sense high BP (from HR)
Raised ICP symptoms (late signs) = Cushing’s Triad:
- High BP
- Low HR
- Irregular RR

What are the appropriate investigations for childhood encephalitis?

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Sepsis 6
LP
- CT head before LP if concerns of raised ICP
Blood culture
Bloods
- FBC, CRP, U&E and glucose
Coagulation profile
MRI - hyperintense lesions, oedema, BBB breakdown
Virus PCR
Further immunological analysis (complement deficiency) if >1 episode of meningococcal meningitis

What are the contraindications to a LP?

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Cardiorespiratory instability
Focal neurological signs
Signs of raised ICP → coma, high BP, low HR
Coagulopathy
Thrombocytopenia
Local infection at LP site
Causes undue delay in starting ABx
Meningococcal meningitis

What is the management of encephalitis?

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IV acyclovir (high-dose) 3 weeks
- HSV is a rare cause but complications are major, so treat empirically
Supportive care – fluids, ventilation, etc.
Other:
- CMV = add in ganciclovir and Foscarnet
- VZV = acyclovir/ganciclovir
- EBV = acyclovir

What is the most common cause of anaphylaxis in children?

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85% due to food allergy

What are the signs and symptoms of anaphylaxis in children?

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Airway → swelling, hoarseness, stridor
Breathing → high RR, wheeze, cyanosis, SpO2 <92%
Circulation → pale, clammy, low BP, drowsy, coma
Skin → urticaria/angioedema

What is the management of childhood anaphylaxis?

* **ABCDE approach** and call for help * BLS might be needed if unresponsive/not breathing * **IM Adrenaline** * Given in thigh * Assess response after 5 minutes and repeat if needed * Monitoring and additional treatment * Establish airway + high-flow O₂ * IV fluids - 20mL/kg crystalloids * IV Chlorpheniramine * IV Hydrocortisone * Salbutamol - *if wheeze*

Describe the neonatal resuscitation guidelines.

1. Dry baby 2. Within 30s = assess tone, RR, HR and colour → *consider SpO2 and ECG monitoring* 3. Within 60s if not breathing = open airway → 5 inflation breaths 1. Reassess = if no increase in HR, look for chest movement → if chest NOT moving → re-check head position, suction airway, other airway manoeuvres → repeat 5 inflation breaths, check for chest movement 2. Reassess → repeat 5 inflation breaths until chest movement seen 4. Chest moves, HR slow (\<60bpm) and ventilate for 30s [rate: 15 over 30s] 5. Chest moves, HR slow (\<60bpm), Chest compressions + ventilation 6. Reassess HR every 30s: if HR not detectable/slow (\<60bpm), consider venous access and drugs 1. NaCl (fluid resuscitation) 2. Adrenaline (1 in 10,000; 0.5mL/kg) 3. Dextrose 4. NaHCO₃ (for metabolic acidosis)

Describe the Apgar score.

What ratio of compressions : breaths should be used in neonates?

3 : 1

What ratio of compressions : breaths should be used in children?

15 : 2

What ratio of compressions : breaths should be used in adults?

30 : 2

If HR does not increase and poor chest movements continue after tracheal intubation, what should be considered?

* **D**isplaced tube - *in oesophagus or right main bronchus* * **O**bstructed tube - *i.e. meconium* * **P**atient * *Tracheal obstruction* * *Lung disorders (lung immaturity, ARDS, pneumothorax, diaphragmagmatic hernia)* * *Shock from blood loss* * *Perinatal asphyxia or trauma* * *Upper arrays obstruction: choanal atresia* * **E**quipment failure - *gas supply exhausted/disconnected*

Describe paediatric BLS.

1. Are they unresponsive? 2. Shout for help 3. Establish an airway 4. Look, listen and feel for breathing 5. Give **5 rescue breaths** 6. Check for signs of circulation (brachial and radial pulses) 7. 15 chest compressions (100-120 bpm): 2 rescue breaths (15: 2)

Emergencies Flashcards

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