Paediatric Emergencies

Question 1

State some common paediatric emergencies

Answer 1

• Cardiac arrest
• Croup
• Sepsis
• Meningitis
• Dehydration
• Febrile convulsions
• Anaphylaxis
• Overdose
• Hypothermia & hyperthermia
• Hypoglycaemia
• Respiratory arrest
• Poisoning of unknown origin
• Pneumothorax
• Peripheral nerve injuries/palsies

*NOTE: some emergencies covered here, some covered in other clases

Question 2

The outcome following cardiac arrest in children is often poor; true or false?

Answer 2

True; problem is usually with respiratory system therefore even if get heart going again it doesn’t solve the problem

Question 3

Management of paediatric emergencies is A-E approach as it is with adults; gauge the normal RR for children of different ages

*don’t need to know off by heart, just idea

Answer 3

Question 4

Management of paediatric emergencies is A-E approach as it is with adults; what could the following clinical findings indicate in a child:

• Bubbling sound
• Harsh stridor & barking cough
• Soft stridor, drooling, fever, looks sick
• Sudden onset stridor with history of inhalation
• Stridor following allergen exposure
• Wheeze
• Bronchial breathing

Answer 4

Question 5

Management of paediatric emergencies is A-E approach as it is with adults; gauge the normal HR for children of different ages

*don’t need to know off by heart, just idea

Answer 5

Question 6

Management of paediatric emergencies is A-E approach as it is with adults; gauge the normal BP for children of different ages

*don’t need to know off by heart, just idea

Answer 6

Question 7

During CPR, what position do you want the head of children:

• <1yr
• >1yr

Answer 7

• <1yr: neutral position
• >1yr: sniffing morning air

Question 8

Describe the pattern of rescue breaths and compressions in child CPR

Answer 8

• Start with 5 rescue breaths
• 15 chest compressions
• 2 rescue breaths

… repeat

Question 9

Describe the pattern of rescue breaths and compressions in child CPR

Answer 9

• Start with 5 rescue breaths
• 15 chest compressions
• 2 rescue breaths

… repeat

Question 10

How should you position your hands for CPR in:

• Infants (<1yr)
• Toddlers/children

Answer 10

• Infants (<1yr): two fingers in centre of chest or two thumbs in centre with hand encircling chest
• Toddlers/children: heel of one hand

Question 11

How should you assess a child who is choking?

Answer 11

A-E

Question 12

How do you manage a choking child?

Answer 12

• Encourage to cough
• Infants:
  
  • 5 back blows
  • 5 chest thrusts
• Children:
  
  • 5 back blows
  • Heimlich manoeuvre

Question 13

What is the most common overdose in paediatrics?

Answer 13

Paracetamol

Question 14

State common clinical features of paracetamol overdose

Answer 14

• None
• Nausea/vomiting
• History of risk factors (self-harm, depression, regular pain relief medications, glutathione deficiency, long term treatment with CYP P450 inducers)
• Uncommon: abdo pain, jaundice, hepatomegaly,loin pain, altered conscious level

Question 15

What investigations would you do in paracetamol overdose?

Answer 15

• Paracetamol level: treatment
• LFTs: monitor ALT for hepatotoxicity
• Clotting screen: functioning of liver
• U&Es: baseline, risk of AKI
• Glucose: hypoglycaemia common in liver necrosis
• Venous gas: acidosis in 10% acute liver failure

Question 16

Discuss the management of paracetamol overdose

Answer 16

• If staggered overdose or timing unclear, start N-acetylcysteine straight away
• If not staggered, >150mg/kg, been <8hrs since ingestion and can get blood results back (and act on them) within 8hrs: do bloods and wait to see if need NAC
• If not staggered, >150mg/kg and been >8hrs since ingestion or cannot get blood results back (and act on them) within 8hrs start NAC

Use graph to determine if need treatment

Question 17

State some potential causes of pneumothorax in:

• Infants
• Children

Answer 17

Infants

• Prematurity (fragile lungs)
• Meconium aspiration syndrome (idea that meconium is thick, when in airways allows air to pass through during inspiration but doesn’t allow air to flow out during expiration)
• RDS

Children

• Primary spontaneous (rupture subpleural blebs tall, thin, adolescent males)
• Secondary spontaneous: CF, asthma, Marfan’s syndrome
• Trauma

Question 18

Discuss the management of pneumothorax in children

Answer 18

Question 19

What is meant by:

• Biochemical hypoglycaemia in a neonate
• Biochemical hypoglycaemia for children older than neonate
• Clinical hypoglycaemia

Answer 19

• Biochemical neonate: 2.6mmol/L
• Biochemical older than neonate: 3mmol/L
• Clinical: glucose low enough to cause symptoms and/or signs of impaired brain function

(according to UHL guidelines gluocse <2.6mmol/L in infant <6months and <3mmol/L in children > 6 months)

Question 20

Discuss the management of hypoglycaemia in children (not neonates)

Answer 20

Depends on if acidosis & hypoglycaemia present. Options include:

• Fast acting glucose (glucose tablets, glucose gel, fruit juice)
• IV glucose bolus
• IM glucagon

Question 21

State some ways you could assess hydration status of infant or child

Answer 21

• CRT
• Heart rate
• Tachypnoea
• Fontanelle (depression)
• Skin turgor
• Sunken eyes
• Urine output
• Dry mucous membranes
• Altered responsiveness

Question 22

State some signs of clinical shock in a child

Answer 22

• Decreased level of consciousness
• Pale or mottled skin
• Cold extremities
• Pronounced tachycardia
• Pronounced tachypnoea
• Weak peripheral pulses
• Prolonged capillary refill time
• Hypotension

**Hypotension is sign of decompensated shock in children and is late sign!!!

Question 23

If a child comes into A&E and there are minor concerns about hydration/fluid intake, what can you do?

Answer 23

Fluid challenge

Question 24

What is the choice of fluids in children (and neonates who are not critically ill)

Answer 24

Sodium chloride 0.9% with 5% glucose

Question 25

Discuss how you calculate paediatric maintenance fluids

Answer 25

**Children (\>28 days of age)** **Routine maintenance fluids** for children are calculated by weight using the **Holliday-Segar** formula:^1,5 * 100 ml/kg/day for the first 10kg of weight * 50 ml/kg/day for the next 10kg of weight * 20 ml/kg/day for weight over 20kg

Question 26

Discuss how you calculate neonatal fluids

Answer 26

**Neonates (\<28 days of age)** Maintenance for **term neonates** is calculated according to their age and weight: * Birth to day 1: 50-60 ml/kg/day * Day 2: 70-80 mL/kg/day * Day 3: 80-100 mL/kg/day * Day 4: 100-120 mL/kg/day * Days 5-28: 120-150 mL/kg/day

Question 27

How can you calculate percentage dehydration by weight?

Answer 27

Question 28

What vol of fluid is used in resuscitation in paediatrics?

Answer 28

10-20ml/kg Use smaller volume in situations such as cardiac failure, septic shock, diabetic ketoacidosis and major trauma. *\*\*NICE CKS SAYS: 10ml/kg for children and young people over \<10 minutes. 10-20ml/kg for term neonates over \<10 minutes.*

Question 29

Describe how you calculate a fluid deficit in children?

Answer 29

* Fluid deficit (mL) = % dehydration x weight (kg) x 10 * \*NOTE: the fluid deficit is corrected over 48hrs*

Question 30

When correcting any hyper- or hyponatraemia you must ensure Na+ does not rise or fall more than ____ in 24hrs?

Answer 30

12mmol/L

Question 31

What should children on IV fluids have checked everyday?

Answer 31

* Plasma glucose * U&Es

Question 32

What is the normal/acceptable urine output for the following ages: * Neonate * Infant * Child * Adolescent

Answer 32

* Neonate (\<28 days): **2-3**mL/kg/hr * Infant (\>28 days to \<1yr): **2**mL/kg/hr * Child: **1-2mL**/kg/hr * Adolescent (10-18yrs): **0.5-1mL**/kg/hr

Question 33

# Define hypothermia Discuss management

Answer 33

* Temperature \<35 degrees * Management: * Remove from sources of potential cooling e.g. remove wet clothes, bring inside * Warmed IV fluids * External warming e.g. Bair-Hugger * Humidified oxygen at 40 degrees *(decrease heat loss through respiration)*

Question 34

State some signs & symptoms of heat exhaustion State some signs & symptoms of heat stroke

Answer 34

_Heat Exhaustion_ * **Hx exposure to high heat or strenuous exercise** * Irritability * Lethargy * Headache * Nausea * Hyperthermia \>38 _Heat Stroke_ * Seizures * Anhidrosis * Impaired consciousness * Temp \>40

Question 35

Discuss the management of heat stroke

Answer 35

* ABCDE * Remove excessive clothing * Rapid acting cooling * Cold or iced water immersion (exertional heat exhaustion) * Wetting and fanning the skin * Wet ice packs * Supportive care (e.g. oxygen, IV fluids…)

Question 36

For iron poisoning, discuss: * Symptoms & signs * Investigations * Management * Complications

Answer 36

* **Nausea/vomiting, abdo pain**, haematemesis, black bloody stools * Investigations: **Fe level, FBC, U&E's, LFTs, CBG,**?axr *(can sometimes see pills)* * Management: * First line= **bowel irrigation** * If severe poisoning then **IV chelation using deferoxamine** * Complications: * Liver failure * GI scarring (leading to early satiety and/or nausea)