Computer generated transcript

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

uh, people. So So the case is So you're on the nation you got called to see meant to any with Strider addressed cough and the past medical history is that he has down syndrome. Let me just check in Malaysia, and that's what the handover has been. So just by hearing, what would you think could be a main issue in any child with Strider addressed and cough? What would the thoughts you have when you first go in? Anyone who wants to give it a go and give some differentials, you can turn on your mike and answer questions. I could pop them in the chart. Yes, you can either pop them in the chat, or you could just keep it interactive and talk to them Any differentials that anyone can think of a four year old boy with strider at rest, rest and cough. Yep. Okay, so the main things that you will be worried for anyone who has especially Children who come in with Strider address would be the most common thing would be a foreign body in addition or foreign body, causing some obstructions, then another thing what you would want to ask them and you see them is is this has this happened before? Like is the child allergic to anything? Because I want to keep that as a differential. And then another thing would be a very still would be the cheapest group. So for us, and he has done so and that. And, um so he does have quite a lot of care with the family as such. So and then the your score was two for him, so he uses just like the new school. But for pediatrics, early one school. So the heart rate is high and the respiratory rate is high. So probably it could be just because the child is distressed at this moment. So the main way to go for me to get a better examination, findings and history. So the main things that you think of one of the main things which is common is so Suppose you get this hand over from your nurses and the message, and then you go to the world or the any area and here, this barking, of course. And then you can more or less come that it could be the crew. So now what is cru? So group is a viral laryngotracheobronchitis, which basically means it's a mucosal inflammation affecting anywhere from the nose to the lower airways. And it's commonly do two para influenza virus, and it can also be due to some other respiratory virus as well. And the main age group that this group affects is usually from six months to six years, and anyone after six years, it's very unlikely that it could be group. So now, coming to a diagnosis. So for group, it's more or less a clinical diagnosis. So your diagnosis is purely based on your history and examination finding. So there are certain things that you need to ask for history in the pediatric age group. But coming to group especially like once you hear this barking sort of sound, then you more or less have an idea that it could be group so you can ask targeted questions to give a better history about group itself. So the main things you need to know is in history is to see if actually group or if it's epiglottis, because if it's epiglottitis, then that could be life threatening and a serious issue. A group. We still have more time and manageable unless it's going to a very severe group. So the main history you need to ask to differentiate between group and epiglottis itis is about the time course that since when did the child or the baby start having the symptoms? Was there any prodromal symptoms like Coryza? Was there any cough, any feeding issues, fever and any strider? So the strider, you need to see if the baby has strider at rest or on agitation. Then on examination, you're looking for the degree of strider. When I see the degree of stress, it's mainly to look at if having any other associated symptoms as well, like any cyanosis or exhaustion and the strider mainly for chest retraction, external retraction thug. So I'm not sure if everyone has seen a tricky drug and appreciated it. So what happens is the trachea not just go early in, so you can just put in the trachea down, so that also is more common in order to severe sort of group. Then the other thing you look for is the respiratory rate and the saturating rate. We know the child is saturating adequately and the high and any signs of so if we are going more towards other differential diagnosis at this point, then we need to rule out all these things before we can say that it's actually true. Then we need to look out for any drowsiness, science or exhaustion like any difficult to wake up. Those kind of things are also red flag signs, so we need to get a senior involved if you notice any of these things happening now. So the main difference between a viral croup and an acute epiglottis itis is basically you get it from the history, so the time cause in croup would be days. So they'll start having some prodromal symptoms, like coryza for a couple of days. And then, after one day one day or two, they'll again start with this kind of barking. It's described as barking seal like off and in a pink lot itis. The time goes, it's just mere us. And then immediately they'll start having symptoms without any prodromal symptoms. So there is a barking seal kind of cough in group, and if they have coughing epiglottitis, it's very mild or miner doesn't produce this, uh, parking type of cough and feeding. Usually in group, they can still drink. But in Epiglottitis, all the kids they start feeds, the path will come, and it's not been eating and drinking. They were really worried, those kind of things. And in group, they usually the mouth is kind of closed. But in Epiglottitis, you can see these babies or Children. They'll be drooling saliva. They wouldn't close their mouth. Usually they'll use their mouth to take more breath in. So, typically, for an older child who can sit up on their own, what we see is the tripod position, so they'll be putting their hands forward, bending forward and taking deep breaths through the amount. So that's why they said, the mouth is not usually called an epiglottis. Itis and Toxic group group. The Children doesn't look that toxic, but an epiglottis they do. So when you say toxic in pediatric age group, it's more or less these Children. They'll tend to be very pale or gray. They might have mortals can maybe showing signs of dehydration, all these of each suggestive of being toxic and even when they might have high fever. When you just go near them, you can feel that heat. But sometimes the things are in babies. They don't usually develop very high fever. Sometimes they can become very cold as well. So even if you see a baby who's very cold and then that is also a sign of severe infection. UH, no fever and group is usually less than 38.5 degrees, while in Epiglottitis it's more than 38.5, and the Strider in group is described as more rasping, sort of try along with the cough. But Epiglottitis is more of a soft strider, and the voice is often hose in group, and it's weak and silent in Epiglottitis, anyone has any questions or anything you want me to talk in particular so far, you could ask questions in the tank box if you want. Okay, and so you can ideally classify group as mild, moderate and severe, based on the retractions, chest attractions and strider. But there is also a Wesley Group score that you can use so the best. The group score has five main domains that we look into, so the first one is the level of consciousness. Then you look at Sinosis, try the air entry retractions, and the scoring is based on how it's shown. So any patient who comes with an older level of consciousness or anyone who has some amount of cyanosis, then that immediately puts them in the moderate to severe score. So that would be moderate to severe group. And if you have Strider along with any of the retractions, then also you will come under the moderate score so mildest when they have so ideally mild will be when you have the cough but no external retraction and no signs of any sinosis altered consciousness. But if you have the cough along with the chest retraction, and then that would be more of a moderate group. If you have the cough with the chest retraction along with signs of exhaustion, that is disorientation of cyanosis, then that is very severe. And if you have all of these and the child starts becoming drowsy, unable to wake them up, then there is a chance of impending respiratory failure, which is a medical emergency. But in group that is very, very rare. But if that happens as a medical emergency, and you might have to call in the anesthetist and the Ent specialist, also along with your pediatric team, any questions so far. Okay, so then coming to the management. So in mild croup, what we usually do is once we have the diagnosis in mind, then we can give you oral dexamethasone. So the oral dexamethasone dose is 0.15 mg per kg. Body weight in Children and what you do is you give the medicine and you observe them for 30 to 45 minutes. And if they once they are improving and if you feel like there's no more barking cough, they have, they're strider, everything is reduced. Then there is a clinical improvement. Then you can discharge them home if it was a mild crew. So if they so then the thing is you need to educate the patients like the parents, especially once your discharging them home. So the main thing is you want to tell them is usually group is will last for 48 to 72 hours, and usually the illness is more at night. So you need to educate them about these things so that they're not worried again and have to come back to the army and the things what they should when they should bring the Children back to anyone with discharges when they have continuous barking cough, even after the next day. And then if you have any strider like continuous stridors as well. And if it's not settling and if the child is crying nonstop without any like without eating and drinking, then those when those signs happen, then you have to bring them back to the knee. That's how you educate the parents. You can also give them leaflets and make sure that they know that it usually lasts for 48 to 72 hours and it gets worse at night. So moderate group What we do is so the main thing while examination is I forgot to mention this earlier. We should not always examine the throat of Children with suspected group, because sometimes if you're worried that it could be, uh, it could agitate them more and make them more distress, especially before you have a diagnosis of group. If you're thinking it could be a pig otitis, then that could cause the firings to close up, and that could put them into a faster rate of distress. So Margaret Group, you try to examine them while they're in the parents lab. Make sure you don't change their position or make them more irritated. Try to settle the child along with the moment, then examine you. So once you come to this diagnosis, then you can give your Alexa medicine 0.15 mg per kg. So sometimes in moderate croup, what happens is the Children will be crying quite a lot and they'll be coughing. And they might even cough out the medicine and won't. They won't be able to take anything in. So usually the parents will tell you he has not eaten anything that's been bringing back everything that he's been eating. And if you're worried that you can't give the adequate amount of medication to the child, then what you could do is you could give Nebulized budesonide, which is 2 mg, and then you observe the child for improvement. So if it's moderate group, you have to observe them for for us, and then you see if they are improving. If they are improving that if if the barking cough comes down, if the strider comes down and the child starts to become a bit more lively than before, then you can distrust them home. Uh, But even after for us, if the child is not improving, then you'll have to admit the child and observe them with a pulse oximeter and shots bro for 12 hours. And you can repeat the dose of dexamethasone after 12 hours of the first dose, and then you see if that's improving and then you can disturb them. Home now Coming to Severe Group Severe Group is a medical emergency, so then you have to escalate it to your seniors. You have to call in the anesthetist or the ent specialist, and you have to immediately start with oxygen and then start with the nebulized. Adrenaline is what we give in severe crew, so nebulized adrenaline. It's 400 micrograms per kg in oneness, 2000 dilution and nebulizer. Adrenaline usually works really, really fast, so you'll see the effects within 30 minutes. And if the child is improving, then you can give another dose of oral dexamethasone at this point and observe the child for two hours, And by this time you'll probably have to admit the child. And if after two hours if the child is improving, then you can give another dose of the exam at the sun after 12 hours. But if the child did not improve after the first two hours, then you have to give another dose of the nebulized adrenaline and see if it's improving. If the child does not improve after three doses of nebulizer vaginal, and then you'll have to intubate the child and has to be transferred to a peak, you for further management. So that's basically the rough treatment for a crew. I know that's a lot, but the main idea is oral dexamethasone is a miracle drug in cases of groups. So for my patient that I saw because he had down syndrome and laryngeal accumulation, the barking cough and the strider was more severe in him because of his other comorbidities. So we initially gave him and, uh, nebulized adrenaline and he improved immediately. So then we didn't have to give him any further doses. So that's the thing. So nebulizer jenaline is only in severe cases, but otherwise oral dexamethasone and educating the parents is the way to go forward. So, do you guys have any doubts? Anything that you want me to address? Any questions? Yeah, Okay. In questions. Okay. Anyone online? Or did I make everyone fall asleep, you know? Yes. You're still very much active here. Thank you very much for going to the management of croup is very, um the way you actually broke it down. Quite knowledgeable as well. Have your patient was Okay. Okay. Um, if anyone does have any questions, I think there's a lot of questions that could be asked. I think you have any questions? Someone here says thank you so much. Very informative. Um, if you have any questions, please, You actually have more time left and and doctor Nadine is actually going to answer questions. You have a pedia Titus and crew between difference. Can we go then, please? Yes, definitely. So the main thing you're worried about epiglottitis is because epiglottitis is also a medical emergency where the er they can close up any time. So, based on history, is how you make the diagnosis between group and epiglottitis. So the time course in group is a couple of days, so they'll have crisis symptoms before for 2 to 3 days. And by the end of the second day, they'll start having this barking sort of cough. So that's how we differentiate with the initial history, whereas an epiglottis itis the time course is within us within us. They start developing the symptoms that they will be out of breath. Take a picnic looking very toxic. Like what I mentioned before, they might be Parexel as well and feeding in groups they still be able to take in drinks. But in Epiglottitis, more or less with all the Children will stop eating and drinking, and the mouth is usually closed in group, whereas an epiglottis itis it's partially open. They'll be ruling saliva and they'll open the mouth so that they can try to get that much air in. So that's where you see the particular tripod position, where they set up bending forward, trying to take more air in. And like I said, the fever is usually very mild fever in group, whereas in Epiglottitis it would be a much higher grade fever. And the strider is more of a fasting sound, So basically the spider is more louder in group than in Uh, Epiglottitis is what they're trying to mean, and the voice is also in. Group is like a very hoarsey voice, whereas the in epiglottis is the Children are too sick that they wouldn't talk much. They'll be very silent. And it's the voice. What comes out is also like a very soft voice. Does that help? And does anyone know What is the bacteria in epiglottitis? This of the virus. So croup is usually by para influenza virus and epiglottis itis is usually by haemophilus influenza. But because of the wide vaccination, it's quite rare to see a patient with epiglottitis in the UK. But in most of the other countries, it could still be a possibility. But because we have a lot of non vaccination, uh, some people are against vaccination, so we'll never know. So we always need to keep this in the back of the mind as well. Yeah. Okay. Any other questions? Um, I I have a question. Um, because I've I've, um I've seen a kid with croup before. Uh, any, uh, my question is this If you have a child with mouth or more really severe cramp that comes into it, um, at what point would you would you want to involve your seniors in terms of like, your consultants or the anus on call, or the ent specialist on call at What point in terms of clinical presentation, would you want to quickly escalated? Yes, that's a very good question. So whenever you see a patient with moderate groups, a moderate group is when you have the cough, the strider and chest retractions, and they're starting to show some features of exhaustion. So model group is around that time. So at that time, you have to immediately give the oral dexamethasone without waiting for any of your seniors. And then you have to tell them you can. You see in this patient is having all these, uh, you observe them for like, the thing is that some medicine works really fast, very, very fast. You'll see the results quite immediately. Like immediately the child will get better. So if you're not seeing those, like observe for, like, 30 minutes, if they're not improving, then you have to call your registrar in moderate group, that is, You call your registrar and let them know they're not improving. So I'm thinking that we should admit this patient, but in severe group is when you have cough strider retractions and the child becomes very drowsy, unable to wake them up. They're not responding or everything together. If you see and very sick looking child, then it is a medical emergency. So then you have to give the nebulized the nebulized adrenaline because they won't even open their mouth to give the oral dexamethasone. So you have to give a nebulizer Virgin Islands and then you call your registrar immediately. And at that time you have to always also inform the anesthetist. I hope that helps. Yeah, yeah, that that would help. Thank you very much for clarifying that metformin. Um, does anyone else have any questions at all or is there anything you want hard to go over quickly for you? Any questions? Okay, so the main learning points are anyone who comes with Strider addressed. Think of foreign body. Think of croup. Think of epiglottitis this so those are the main things. And the treatment for croup is oral dexamethasone. And honestly, I'm telling you, it works like magic. That does. They do improve Much better, like very fast. In 30 minutes, you will definitely see the improvement in the Children. Okay? Okay. Um I think I think the question Okay. Regarding the door, it's 0.15 mg per kg for oral dexamethasone. And I think the subcutaneous dose is, uh the intra muscular dose is 0.6 mg if I'm not wrong, but the oral dexamethasone is 0.15 mg per kg. Thanks. Um, good interaction by everyone. Um, you have any other questions at all? Just keep them coming, and yeah, okay. All right. Um, if we I'm having trouble connecting to the Internet. Yeah. Mhm. Any questions regarding any pediatric cases? Like any If you want to just go, like what? History and things that you need to ask. Also, we can discuss that if anyone wants to have a quick revision, All right, Everyone is quite okay. So we can, without any further questions. I think we have come to the end of today's, um, again. Thank you very much for, um, Cavanaugh. Time from your busy schedule to be here. I hope this was helpful in some way to everyone. It was. It was It was sorry. My camera. It was extremely helpful. Um, especially managing. Haven't seen one before, and I haven't management before. Um, having a teaching, and then that will be here. It's actually really useful. Um, something else. Just add to it. so this teacher will remain on the platform. Um, just like the previous teachings about reflection, they will be here. Um, I would also appreciate if you could, um, give feedback. Um, What we need to work on what we need to improve on and how you would want to teach them to deliver. That would be really useful. Um, if you do haven't met all profile, I think you know that your disease educated and teaching will be somewhere in your achievement area. So you can pop in here and check it out as well. Um, are teaching sessions will continue weekly. Um, we'll keep sending out emails. So if you do want to be part of it, I think you could either join us a member to the profile. I think so. I'm not quite sure. Um, I think someone have a question for you, to be honest. Uh, prove it. Infection. Bacteria superimposed. Have you, um, can Okay, So, um, are you trying to question if, if it's superimposed with bacterial infection, how would you manage If is that the question? Yes. Okay. So usually there's no clinical tests that we can do to diagnose group as such because it's mainly uh, I mean, no investigation can diagnose it because it's more of a clinical diagnosis. But the thing is, if the patient has this very prominent barking sort of cough, then it gives away that's more of a group. And it's very rare to get bacterial infection along with group, because sometimes what you could get more often is bacterial bronchitis. So there you wouldn't have this barking sort of a cough. It's more just the bacterial infection where you can give the antibiotics. But if if there's high suspicion that there is a bacterial infection, you can do the bloods and see. Usually we don't do bloods in all Children, Um, because because it's quite traumatizing, so you only do it when there's a high suspicion. So if you feel like oh, this child is having very high temperature, unlikely that this child should have such a high temperature in croup. And if you're worried about that, then you can just do some blood. And if it's showing something like elevated infection markers, then you can start them on an antibiotic cover as well. But otherwise, uh, if they're not having that high fever and those kinds of things, then you wouldn't suspect it to be a bacterial infection. So if they present with any sort of very high temperature vomiting, diarrhea along with these along with the cough and symptoms, then you could suspect there is some of other infection ongoing as well. Thank you. Good stuff. Good stuff. Hurt. You have any questions or cold? Thank you. All right. Um, I think we could spend a few more minutes for more questions to rule in. Yeah. Uh huh. It's very interactive. So So Okay. Mhm. Yeah. Stuff. Mhm. Okay. Yeah, yeah, yeah, yeah. So Okay. So if they if they're normal questions, um, we're always happy to answer questions. Um, it's a problem in the child, but if normal questions, um, I wouldn't want to keep you here longer than you're supposed to know. Everyone have, um, something special for the rest of the evening. Um, again. Thank you so much for making time today. Everyone likes her life. Thank you so much for being here and attending this tissue. And we really do appreciate that. Um I think we have I think we have more. You know, uh, is happy And group both in management. Like first line. Um, I didn't really fully understand the question, but I'm trying to ask if, uh if adrenaline and dexamethasone is both the first line in management. Okay. Is that the question? Sorry. I didn't really understand the question. Yeah. Yes. Okay. So, um, it the first line would be dexamethasone if it's mild or moderate. Group. If it's very severe group, then only then do we give the nebulized adrenaline. Because the severe group is when you have the parking of the strider, the chest retractions along with any other features, like child becoming very drowsy, unable to wake up any features of cyanosis becoming unresponsive. Then there it is very severe. There, you can't even give the oral dexamethasone. So there you have to give the nebulized adrenaline first, but mild and moderate group, you give that aura like some it. This one. Okay, so what if the child doesn't respond? But the symptoms are that of mild. So if the symptoms are mild, that if they just have the barking cough without any strider or things, then you give the dexamethasone. Ideally, it should help. But if it's not helping, then you have to admit the child, and you have to observe them to see if they're worsening. If there's any worsening, you can repeat the dose of dexamethasone after 12 hours of the first dose.