Computer generated transcript

Warning!
The following transcript was generated automatically from the content and has not been checked or corrected manually.

Common Paediatric Emergencies Dr Yashasvi Rajeev ST2 PaediatricTrainee Royal Brompton Hospital Guy’s and St Thomas’NHS FoundationTrust LondonDisclosures and conflicts of interest  None  Apart fromTopics Covered  The need for rapid assessment in children  How carry out a 3 min exam  Traffic light system for assessing unwell children  Febrile child  Respiratory disorders  Limping child  Trauma  Non-accidental InjuryWhy do children require immediate attention ? In an emergency situation , a child’s condition can deteriorate quickly due to the following factors – ▪ Anatomical differences - small airways and fatigable respiratory muscles ▪ Physiological differences – hypoglycaemia is poorly tolerated ▪ Developmental differences – neonates and small children have immature immune systems ▪ Inability to communicate the seriousness of the problem ▪ Altered illness responses – diseases like meningitis may not produce stiff neck, vomiting in UTI ▪ More recently in diseases like COVID-19 – altered immune responses leading to conditions like Paediatric Inflammatory Multisystem Syndrome (PIMS-TS)Vitals For Different Pediatric Age groups Age Normal Normal Heart Normal Optimal Respiratory Rate Systolic Blood Weight Rate Pressure At Birth 25-60 120-160 50-70 2.5 -4 kg 6 Months 20-40 110-160 65-105 7-8 kg 2 years 20-30 100-150 70-110 12 kg 5 years 20-30 80-135 80-120 18 kg 10 years 15-25 70-120 80-120 32kgHow to access the optimal Weight For estimated weight formula can be used –  Forinfants< 12 months:Weight (kg) = (age in months+ 9)/2  Forchildrenolderthan1 year:Weight(kg)= (age(in years)+ 4) x23 min examinationIbuprofen  Do not give ibuprofen to - ▪ Children under 3 months ▪ Children with suspected chickenpox ▪ Oncology patients ▪ Children with asthmaFebrile Child - Convulsions  Febrile convulsions are common manifestation of fever (3% of children experience febrile convulsions) and is between age 6 months-3years  Generalized, short duration (<15min ) seizures  Occurs when temperature reaches >38.5 degrees centigrade  Aborting the seizure– most FS episodes are short-lived and self-terminating and do not require long-term treatment with antiepileptic drugs.  In a child who is still convulsing at presentation to the ED, indications for giving antiepileptic drugs are seizures lasting more than 5 min, febrile SE, and recurrent seizures.  Follow ABCs and the initial drug of choice is Midazolam 0.3–0.5 mg/kg buccally or Lorazepam 0.1 mg/kg IV or IOPaediatric Patient in ShockRespiratory Disorders Upper Respiratory Disorders Lower Respiratory Disorders Croup Asthma Anaphylaxis Bronchiolitis Foreign Body Obstruction Pneumonia Bacterial Tracheitis ( Epiglottitis) Croup  Viral tracheobronchitis caused by Influenza and parainfluenza viruses – coryza precedes the cough (Barking Cough )  Stridor at rest is an indication of severity – requires acute assessment and treatment  Cyanosis is a pre-arrest state  Oral dexamethasone or prednisolone reduces the risk of intubation, first line treatment  If not tolerated IV/IM Dexamethasone or nebulised Budesonide can be administered  In severe croup, nebulised adrenaline (0.5mL/kg of 1:1000 for maximum of 5 mL)StridorForeign Body Inhalation  Can be the cause of acute distress, quite often between children aged between 6 months and 2 years  Symptoms include –Choking, coughing, difficulty breathing and shortness of breath, difficulty speaking, wheezing or stridor.  Encourage the child to keep coughing. If the obstruction is mild, they are usually able to cough and clear the blockage themselves.  If airway is completely blocked – ▪ Conscious – Rapid back blows in an infant or the Heimlich maneuver in an older child should be performed ▪ Unconscious – Open airway, 5 rescue breaths and CPR  Rigid bronchoscope can be used to visualise and remove the foreign object if in upper airway, flexible for lower Bacterial T racheitis ( Epiglottitis)  Caused by H. influenzae  Child presents similar to croup, however child is unimmunised.  Disease rapidly progresses over hours and the child drools, is unable to phonate and assumes “sniffing air position” to maximize airway caliber.  Enlarged epiglottis visible on Xray (thumb sign )  Cyanosis is pre-arrest stage  Initial treatment in pre-arrest stage is transfer to operation theatre for administration of inhalational anaesthetic and intubation rd  Once airway is controlled , take a swab and commence IV 3 generation cephalosporinAsthma  Very common in children  Signs of severity include tachypnoea, intercostal recession, use of accessory muscles, prolonged expiration, cyanosis and altered level of consciousness  Classical wheeze can be heard  For children under 5 with suspected asthma, treat symptoms based on observation and clinical judgement, and review the child on a regular basis  Exacerbations are treated with salbutamol initially with spacers or nebulized salbutamol, ipratropium, or MgSO4  Short course of oral steroids for 3-5 days is also recommended , which can be IV for severely ill patientsWheezeBronchiolitis  Viral infection of lower airways by Respiratory Syncytial Virus  Common in children aged between 2-6 months  Disease progression: 1-2 days of coryza, increasing respiratory distress with tachypnoea, nasal flaring, wheeze and fever .  There may be apnoea or difficulty feeding in severe cases .  CXR- can be normal or show hyper-inflation of lungs in 50% of cases  Treatment involves –Supplemental Oxygen with humidification in severe cases.  A trial of bronchodilators and steroids may be warranted in older children  IV fluids should be given in patients who are not feeding well and are in distressPneumonia  Auscultatory signs are subtle, and X-ray is usually needed to confirm the diagnosis  Causative organisms can be ▪ Bacterial - Strep pneumoniae , Staph aureus (in those aged < 5 years) , Mycoplasma pneumonia ( <3 years) ▪ Viral – Influenza, Parainfluenza , Respiratory Syncytial Virus (RSV), Epstein- Barr Virus  Treatment is with antibiotics – oral or IV based on trust guidelinesCauses of Limping – Under 3 years  Septic Arthritis /Osteoarthritis- 4 criteria (amended Kocher’s Criteria) - 1. Fever >38.5 2. Unable to bear weight 3. CRP>20mg/l 4. WCC>12 ▪ Child is extremely unwell and passive movement of joint is painful ▪ Septic Arthritis is a medical emergency requiring urgent treatment – Drainage of joint and IV antibiotics  Transient synovitis – less common in children below 3  Fracture  Developmental dysplasia of hip  Non accidental InjuryCauses of limping –Age 3-10  Transient Synovitis - • Acute onset, following viral infection , no systemic upset • Most commonly occurs at age 5-6, boy are affected more • No pain at rest and passive movements are painful only at the extreme range of movement • Treatment is oral analgesia  Septic Arthritis  Fracture/ Soft Tissue Injury  Perthe’s diseaseCauses of limping - > 10 years old  Septic Arthritis / Osteomyelitis  Slipped Upper Femoral Epiphysis – Occurs in 11-14 years, overweight children • Presents as knee pain • Same day Xray is crucial – delayed treatment leads to poor outcome • Failure to treat a SCFE may lead to: death of bone tissue in the femoral head (avascular necrosis), degenerative hip disease (hip osteoarthritis), gait abnormalities and chronic pain.  Fracture /Soft tissue InjuryCauses of Limping unrelated to Age  Malignancy  Metabolic Diseases - Rickets  Non-malignant haematological causes – haemophillia , sickle cell  Limb Abnormality - length discrepancy  Neuromuscular Diseases – Cerebral Palsy , Spina Bifida  Inflammatory joint disease – Juvenile IdiopathicArthritis(JIA) - Bilateral , groin pain referred to thigh or knee, morning stiffness with gradual reduction of pain on activity . Treatment is Intra-articular steroid injections and Nonsteroidal anti-inflammatory drugs (NSAIDs), including ibuprofen and naproxenInjury and Trauma in PaediatricsDiagnosis  Paediatric Glasgow Coma Score – it can be used in patients who have not yet developed language skills. Any combined score of less than eight represents a significant risk of mortality.Paediatric T rauma  Always remember A to E assessment  Get senior help early  Crucial to learn the differences between Paediatric and adult CPR (ALS and EPALS are good resources) –30:2 vs 15:2  Every hospital has a Major Trauma protocol – 2222 to activateNon- accidental Injuries  Safeguarding is an essential component of any paediatric consultation.  Bruises – worrying shapes like hands, linear, identifiable implement; worrying patterns like clustered bruises; bruises in a child who cannot mobilise  Lacerations- Highly suspicious lacerations like those seen in non-mobile children , around the face and those around wrists or ankles ( think potential ligature )  Thermal Injuries – Unusual locations like soles of feet, buttocks/back or back of hands with sharply delineated borders  Fractures- Single or multiple fracture in children without a medical condition fractures of different ages, metaphyseal corner fractures, spiral fracturesDifferentials in Non-traumatic Injuries  Osteogenesis Imperfecta- Family history may be present, skeletal survey  Coagulopathy – Family history, coagulation screenHow to deal with NAIs  If suspicious, never hesitate to ask seniors for help  Various therapeutic interventions can be taken to ensure the safety of paediatric patients 1. Social workers 2. Child and adolescent mental health practitioners (CAMHS) 3. Voluntary SectorAgencies – like Red Thread, St Giles  The choice of intervention should be based on a detailed assessment of the child or young personReferences  The fundamentals of Emergency Medicine – by Cliff Evans and Emma Tippins  Emergency Medicine – Principles of practice (6 Edition)–By Gordian Flude and Sacha Flude  NICE guidelines  NHS Guidelines  Traffic lights V4:Layout 1 - West Suffolk Hospital  Pediatric injury patterns by year of age - Elizabeth Tracy et al J Pediatr Surg. 2013 Jun  Royal College of Nursing – Standards for Assessing , Measuring and Monitoring Vitals in Pediatric Age Groups  COVID-19 in children and altered inflammatory responses - Molloy, E.J., Bearer, C.F. Published in Pediatric Research – March 2020