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Fine. So I'm Yash. Uh I'm a pediatric training at the Brompton and currently I'm just going to talk about pediatric emergencies. And I've tried to kind of make this talk more about more for med students when you first walk into the emergency department, for you not to be scared if you see an emergency there and kind of have an idea of what to look for because most often as medics, we are really scared about kids because we don't really spend that much time of our med school learning about pediatrics, we learn more about adult medicine. So sometimes it's a bit new and scary bit of disclosures and conflicts of interest. Pretty much none apart from, I'm a huge mclaren fan. So any formula one chat afterwards, willing to talk about it, but nothing else apart from that. So the topics covered today, why do we have a need for a rapid assessment in Children? How to carry out a three minute examination, a traffic light system which is we commonly used to assess unwell Children. Uh What is and how is a febrile child different from febrile, adult, common respiratory disorders, limping child? A bit of pediatric trauma and a bit about safeguarding and non accidental injury. So first of all, starting from the top, like why do kids require immediate attention? Yes, everybody who comes into the emergency requirement department needs our attention. But why do we need to pay extra attention to kids so kids can deteriorate quite quickly? Does anybody know why? Just like shout out things or type it in the chart? Why do we think like kids need extra attention first? Anything? So there's no right or wrong answers. We are all here to learn. So anything is, yeah. So why do we think like a child coming in needs an immediate and urgent assessment as opposed to an adult? No. Ok. So we have anatomical differences. So kids have smaller airways and fatigue will reserve uh respiratory muscles. What I mean by that is they don't have much of a reserve. So as an adult, even if they are having respiratory problems, LRTI S they can kind of chug along and maintain the low reserve for a long time, kids don't have that. So what you typically see is they'll manage, manage, manage and then they'll suddenly go into respiratory arrest. So we need to pay attention to them quickly, physiological differences. Hypoglycemia is poorly tolerated similarly because they don't have much reserves. So even like hypoglycemia is poorly tolerated by the pediatric brain. So again, we need to pay attention more quickly. So if you get a child who's been vomiting for a while, you need to pay attention to their BMS because this can drop quite precipitously developmental differences. There is, there are a lot of like immunological differences. As we all know, kids don't have mature immune systems, they probably don't have all their jobs up to date yet. They are still in the process of building up their reserve. So again, they can catch infections and can cope poorly. Finally, uh it's also about having a difficulty in communicating the seriousness of the problem. You don't know why the child is crying. You don't know what's happened. A child can't communicate and say, oh, I'm having burning micturation or I'm having difficulty breathing. So, hence, you need to assess them quickly to find out. Is it meningitis? Is it uti what's going on? They can also have altered immune responses. Disease like meningitis, which we typically learn in med school produces stiff neck. We don't see that things like UTI can have symptoms of vomiting rather than dysuria because a child can cry for any reason around the earth. So uh they might just have vomiting as a reason for uti. So again, altered immune responses. And finally, uh for diseases like COVID-19, they're having different responses as opposed to the responses we expect in an adult. So they have conditions such as PT S for COVID-19, which is not even seen in adults. So because of all of these reasons, kids need immediate attention as opposed to adults next, coming down to vitals. We need to understand. First of all, what's normal for us to know what's abnormal for kids. They breathe fast. Their heart rates are fast and their blood pressures are low. This is a rough guide just for you to have a rough idea of what's normal. So a child's normal respiratory rate is between 25 at a neonatal birth is between 25 to 60. So if somebody comes up to you and says, oh, there's a child whose breathing rate is a neonate whose breathing rate is 18. Normally, if it's an adult, you would not be worried. But for a neonate, you should be really, really worried. Same with the heart rate, a neonate with a heart rate of 100. We are scared a heart rate below 60. We start CPR. So as you can understand like the metrics that how we assess things are very, very different. Uh Same with the BP and the optimum weight if you can't remember them, what we usually do is we have a quick guide on a Lanyard and we kind of use this to assess, but just for a rough idea of a heart rate between 120 to 160 is normal for a new unit and it goes down, a BP between 25 to 60 is fine for a unit and that goes down as well as for the weight. Weight also plays a huge role because we do a lot of weight based banding of hard drugs a little bit is age based, but a lot of it is weight based. So we need to know what the optimal weight is. These are the formula that we use. So for uh infant, under 12 months, we just uh you estimate the weight and age in months plus nine by two. And for Children older than one year, it is age in years plus for multiplied by two. The reason we sometimes need to estimate is you don't know in what condition the child is coming in. Have they been having a lot of diarrhea? And sometimes it's such an emergency. You cannot remove all the drains, all the masks, everything and put them on a vein machine. So you kind of have to estimate a weight more often when they come by a blue light. Now, I have this video for a three minute examination. I really like it because it kind of goes from head to toe and gives you a rough idea of how it is to examine a child. There's one thing in this video that is highly unrealistic and that is that the child is sitting calmly. No child will ever be calm when they come to A&E they'll be screaming their head off. And that is part of your skill set. When you examine a child of how you calm them down. Can you stickers, lights anything to keep them calm and distract them. And once that happens, this is how you examine them. Let me know if this is part of the consultation. After the history has been taken, a general impression of the child will already have been gained. Look at your tummy first. Can you sit up first? The doctor counts max's respiratory rate over 30 seconds while he is settled. She uses this opportunity to also listen for any airway noises and observe any recession of the chest wall. She then listens to his chest and heart sounds breathing rather than listening to the back straight away. She keeps him sitting on his dad's lap as he is and checks the temperature of his hands and his peripheral and central capillary refill. She then turns Max around so she can listen to the back of his chest multi pregnant for me. Very good while he remains settled. She uses the opportunity to feel his abdomen still on dad's lap. This should be done on the trolley if you either suspect or detect any abdominal pathology. Next, she switches on the pulse oximeter which measures his oxygen saturations and his heart rate. If he had been very unwell or unconscious, she would have also checked Max's BP. We always lastly, she looks in his ears and throat. I'm just gonna put that on your tongue so that I can see if the back is ok and checks his temperature using a tympanic thermometer. If he had been very unwell or drowsy, she would have checked his blood glucose. That examination took about three minutes, but it was systematic not have missed any serious acute illness. If you find any abnormality, a more detailed medical examination of that system is necessary. For example, a thorough neurological examination benefit of being systematic. Like this is not to miss anything out and to pick up abnormal signs. If the diagnosis itself is not clear, it doesn't matter. You will have picked up enough information to know if a child needs an early review or referral to hospital. The checklist can also help to reassure you if you think a child is well but are unsure of yourself. So as you can see here, if we always go by a methodical approach rather than something doing haphazardly, even if somebody comes in with a trauma, anything, no matter what happens, always go a to e it really, really helps. So we'll just break down the components we joined consultation, see where we were. Yeah. So we go with starting with a look at the airway C. Is it, are they having secretions? Are they cough? Coryzal, listen for airway sounds while that is happening. You also assess the breathing. See the increased work of breathing, you'll use that word, uh you'll see that word used all over in pediatrics. It's the work of breathing. Is it subcostal recessions? Is there a tracheal tug and assess accordingly? Look at circulation, see the cap refill. And finally, with the d look at the pupils, look at the ent ear, nose throat with other medicine. We are not so used to doing that, but most more often than not, it's either otitis media or tonsillitis. That can be the cause. So this is how we go about it. And this, if you, if I want you to take anything away from this presentation, it's this slide, Uh you should know this by heart, know what is abnormal and then, then you can escalate it appropriately. So this is what we call the traffic light system. Uh The one on the left is when everything is normal, it's green. So the color of the skin, the pallor if it's normal color, nothing to worry about. Uh amber is if there's a pallor reported by the parents, it could be anemia, it could be blood loss if they are very pale mottled, then that is red. That is high risk. That means immediate escalation to the consultant. Uh Next one as activity. Are they responding normally? Are they content? Are they staying awake? The amber one is that they're not responding to cues, no smile, they are just awake but they are not that responsive. Finally, the last one is no response at all appears ill, does not stay awake. And things like this. The most important assessment that we can have is of the parents. When the parents say that the child does not feel right. They are more often right? Because we are only going to spend 5 to 10 minutes, but they know their child. So even if you have a normal set of orbs, don't discount it. If the parents says that the child doesn't feel right, make sure you do a thorough examination. Next is with the respiratory. If it is normal, it is green and amber. If you see nasal flaring or if it is tachypneic. Obviously, if they have low sides, if they have crackles in the chest, that is amber, if they are grunting, tachypnea, respirate over 660 or severe chest in drawing, that is red, it's circulation normalized moist mucous membranes that's normal in amber, you have tachycardia, heart rate over 60 in this age range. And as it's below cap, full time, always, always do central and peripheral because more often we just look at the central and we're happy, make sure it's central and peripheral dry mucous membranes, poor feeding. Now, that is again, a thing that we assess and how we try to quantify it because we ask the parents, are they eating less than 50% in the last 24 hours? If it's less than 50% we are really worried a little bit less we can tolerate. But if it's less than 50% we are really worried and again, reduced urine output. So what we mean by that, if a child has not passed urine in more than 12 hours. We are very, very worried. So a normal child should be passing, even if they're unwell, should be passing urine at least every 12 hours and red is reduced. Can t finally, the other signs are if the age of 3 to 6 months and a temperature of 39 degrees, we are worried fever for five days. We are very worried because that could be a sign of an untreated infection. And then we usually like to do bloods. Are they having dry gauze? Are they having swelling of any limb or joint or not weight bearing red? And this is very important if their age is less than three months and a temperature over 30 that should flag all the red signs that you have. If a child is less than three months has a temperature over 38 degrees, we want to see them fast, we want to give them antibiotics fast. Yeah, a non blanching rash again. A sign of meningitis should be seen fast and immediately bulging fontanel until the age of one, they have a fontanelle. And you should feel that as a part of an examination that can again give you an idea of how severe the infection is. If it is an extremely sunken fontanel, you are thinking dehydration. If it's bulging, you're thinking of meningitis, neck stiffness as it's a no brainer again, uh a red flag sign status, epilepticus seizures as well. So what do we do. Now, we have classed them in all these categories. Now, how do we go about it? If it's a child younger than three months of age, do the obs if you're worried, then perform a full blood count crp blood culture test for UTI, which is again, easier said than done because kids will not need neatly pass urine into a bottle. So that's involves a lot of waiting but make sure that it's a clean catch because a contaminated catch of urine again is meaningless chest X ray and examining that and stool culture if there's diarrhea, if they are meeting the red flag signs, if it's a child, less than three months with a temperature of more than 38 degrees, we have to do a lumbar puncture on them because there's a very high risk of meningitis. So as you can imagine, that's very traumatic for the parents, very traumatic for everybody else. So make sure you're confirming that the temperature is more than 38 degrees before going down this route because that will require admission for at least three days. Yeah. So younger than one month or 1 to 3 months appearing unwell having blanching, uh non blanching, rash mort and uh temperature over 38 degrees. So you go down this route. If they are three months or older, then we go down based on if it's green, amber or red. If it's green, you're still suspecting an infection. Do a urinary test for a uti, we don't routinely perform blood tests on Children. So because again, it's traumatic for the Children if it's a fever, less than five days, we don't normally do that. We just see, assess, try to find the source of the infection and then you can ask them to follow up with the GP if there's any amber signs or you don't have a diagnosis. Again, we go down with full bloods, uh CRP blood culture and urinary tract infection and you can perform a chest X ray and we can consider a lumbar puncture if we are seeing signs of meningitis, but we don't usually do that. And obviously, if there's any red signs, we go accordingly and we also perform a blood gas BMS just to make sure everything else is fine. Yeah, and more important is a safety netting advice. So there are loads of websites you can find online for you to give safety netting advice because the child might be well with you at the moment. But what if they go home and three hours later, their, their uh green signs become amber or their amber become red. So the parents need to be on the same page and need to understand what to do in case they derate. So now moving on to specific signs and symptoms for specific diseases uh for meningitis as II think you guys will know it's a non blanching rash, there will be lesions larger than two millimeters, cap ref greater than three seconds. Sometimes they have neck stiffness. Sometimes they don't, child looks really, really quite unwell. The meningococcal meningitis with meningitis, they also have bulging fontanel decreased consciousness. Sometimes they can even have seizures uh with herpes encephalitis. They have focal neurological symptoms, some sometimes focal seizures sometimes and decreased consciousness. So those are the neurological ones with pneumonias. They'll be tachypneic, they'll have nasal flaring chest and drawing sinos low t in the chest with UTI S. This is a very important thing as well. Uti S in Children are associated with vomiting. So if a child is vomiting a lot but not having diarrhea, suspect uti right on top of that, they can have abdominal pain and tenderness. They can have lethargy, they can be irritable. Sometimes parents will just say child is otherwise fine, just has fever and offensive urine. Again, that's a sign of uti septic arthritis. Also something to keep in mind. If they're having swelling of a limb, they're having temperatures, they're not weight bearing, not using any extremity. And finally something a small note on Kawasakis, this is something that can happen and can be quite devastating if not caught. So if there is having a fever longer than five days and have at least four of the following five symptoms, that is bilateral conjunctival injection changes in the upper resp tract, it will look what we use. The typical term is strawberry tongue or injected pharynx. They'll have dry, cracked lips, change in the peripheries, they'll have peripheral edema, they'll have peeling skin as the term we normally use polymorphous rash and cervical lymphadenopathy. Those means ivig and aspirin and they need to be referred to a cardiology center. So just make sure that you don't miss the signs for Kawasaki. Special note on certain meds that we take for granted. Normally, we do not give ibuprofen in Children under three months. Uh We do not give them the reason we don't give it for Children under three months is because they've been known to cause renal failure. So, unless indicated, try to resolve the fever with paracetamol, we don't give them in Children with suspected chickenpox. Now this is something which also sometimes trips people up because parents will come in with a child with chickenpox and then they'll say they've been giving them loads of ibuprofen. It's been known to cause S pe. So we avoid chickenpox because it can cause nasty bacteria infection. So when kids have chickenpox and they take ibuprofen, we do not give them in kids with uh oncology patients. Again, a reason with that being that because they are on patients, they have, they can have massive bleeding. So you want to avoid that uh gi bleeding. So hence we give on your paracetamol and we don't give them in kids with asthma because that can exacerbate the asthma. Now coming to febrile convulsions uh with febrile convulsions, that's common in kids between six months to three years. 3% of kids get febrile convulsions. Again, an important thing to note parents. The second they get febrile convulsions they are worried about. Is it a lifelong diagnosis of epilepsy? And we need to differentiate the two? They are completely different. Most kids who have febrile convulsions will never end up having epilepsy or requiring medications for uh in their adult life. So what are febrile convulsions? They are short, generalized seizures lasting less than 15 minutes occurs usually when the temperature reaches more than greater than 38.5 aborting the seizure. Most of them are shortlived and self terminating. Most of them do not require any medications. Most of the kids who will come and will never have had seizures before. Sometimes there is a family history of febrile seizures or other siblings who have febrile seizures. But more often than not, it will be first time they were having a temperature otherwise fine suddenly start having seizures. If a child shows up who's still convulsing and uh seizures are lasting longer than five minutes, you need to give them antiepileptic medications. Follow E to E and then the first medication that you gave first line is midazolam, 0.3 to 0.5 buckle or if you have IV access, give them no as IV or IO it can be quite stressful for the parents. So the most important thing is you make sure that you're not forgetting anything else while you're going on the diagnosis of febrile convulsions. What I don't want is sometimes people think it's febrile convulsion, but it might be something else. It might be meningitis, it might be encephalitis. So make sure that you're really, really sure when you're sticking to the diagnosis of fibrile convulsion and you have identified some other source of the infection which is leading to the fibrile convulsions. Next thing that I want to talk about is a big shock. I don't know if you guys have previously heard of this before. The most common algorithm which we use is the red flags. This you'll see in every pediatric emergency department. The second you get a blue light call, they'll be like, oh let's write down the red flags. What we mean by that is we do all the things required so that the second the child walks in, everything is ready. So let's start with the W the W means weight, we estimate the weight. So with the formula that I mentioned before, an infant weighs about 3 kg, we estimate the weight and we make sure that we have the weight, right? E is for energy. We are, if we are seeing VF or pulseless VT, the energy that we go by, by four joules per kilo and we round up. So if it's, if the, the setting is between 100 and 150 we go to 150 if the full joules per kilo goes to that. Next is for the ET tube. These are the lengths for the ET tube that we measure for the uncuffed tubes based on the age and ills with the fluids. We start with 20 mils per kilo for uh of 0.9% normal saline via IV or IO. And in known cases of trauma, we go with 10 mils per kilo rather than 20 as we mentioned before, the LORazepam in case of seizures and can be repeated after 10 minutes. Again, 0.1 mil per kg uh milligram per kilogram, adrenaline dose 0.1 mg per kilogram and one in 10,000 IV or IO given in cases of VF uh pulseless VT after the third shock or in asystole and also with glucose of two mils per kilo of 10%. You need to give it at the BM as below three. Now coming to respiratory disorders. Uh Have you guys normally gone to emergency departments? Do you know what the common respiratory ones are? I would like this part to be slightly more interactive. So if you can type, what are the common respiratory disorders might show up in ed if you can just type in the chart. Yeah, bronchiolitis. Good. What else? Yeah. Epiglottitis. Anything else group? Yeah. Yeah. Viral induced wheeze pneumonia. Yeah. All common stuff. Yes. Foreign body. Very important foreign body and a very common one. It's seasonal. It's winter right now. Familial history. Yeah. Asthma, exacerbation. Perfect. These are the answers I was looking for. Perfect. Yeah, you guys have already answered all of them. Yeah. So we're dividing them into upper and lower upper respiratory. You can have croup, you can have anaphylaxis, you can have foreign body obstruction or you can have epiglottitis and the lower respiratory tract ones are asthma, bronchitis and pneumonia. So, starting with group. So croup is a viral tracheobronchitis usually caused by the parainfluenza or influenza viruses. Usually they will have Coryza for a couple of days and then suddenly they will start having the barking cough, they'll have strider at rest. Uh A strider at rest is an indication of severity and requires immediate assessment and sinois is a pre state. So normally, what we do is if we are hearing a croupy kind of cough, we start with an oral dexamethasone or prednisoLONE which reduces the inflammation. So what how I understand is with physiology is if there's a turbulent airflow. So if the airway has an inflammation, the air becomes turbulent and when the child is breathing, that's when you hear the cough. And what the dexamethasone or prednisoLONE does is it reduces the inflammation, does increasing the diameter of the airway and reducing the turbulent airflow. You're not treating the infection per se, but you're making sure that the airway is patent and they can breathe normally. So normally we start with oral dexamethasone or pred. If they are not tolerating, we can go I vi M or nebulized budesonide. If they are really, really bad, having low sats not improving on oral dexamethasone, you can even give them nebulized adrenaline. Yeah. So now I'm going to play the sound of Stridors. I want you guys to have a listen. So you know what it sounds like? Ok. Mhm. What? Ok. What? Ok. Ok. You too. It is a high pitched whistling sound and normally, yeah. Next come into foreign body inflamation, uh inhalation. That can also be a cause of stridor can be a cause of acute distress in a child age between six months to two years. There have been loads and loads of cases where a child has been incorrectly diagnosed with asthma have been on the ward for six hours, eight hours. We are giving them everything else. They are not improving. Then we do a chest X ray and that's when we see, oh, they have inhaled a foreign object. So always, always make sure do they have any history of anything else? Any preceding illness? Any fevers, anything else? Because if they have that, then it is unlikely to be a foreign body. But if the parents say, oh, they were fine, they were playing with the older sibling and then now suddenly they have developed this problem. It could be a foreign body inhalation. Yeah. Symptoms can include choking, coughing, difficulty, breathing, shortness of breath, difficulty, uh speaking, wheeze or Stridor. Yeah, encourage child. If you see a child there is a foreign body, encourage child to keep coughing. If the obstruction is mild, they are usually able to cough it out if the airway is completely blocked and they're conscious, you perform the rapid uh five blows to the back or the heimlich in an older child. I would like you guys to refer later on to the EA S guideline on how to do uh how to remove foreign body in a child, uh which is different from how you do it in an adult. Basically, it's five back flows and five blows to the chest and you alternate between the two and if they are unconscious, then obviously you go up the airway, give rescue breaths and start CPR normally, a rigid bronchoscope is then used to visualize and remove the object and flexible. If the object has gone down, lower, some say something, it is like a peanut which has gone down to uh the lower airways. Then we use a flexible bronchoscope. Next. Coming to epiglottitis usually caused by h influenza. It is seen in cases where kids are unimmunized, similar to croup, but the child is immunized disease progresses over hours. Child, you will see a child drooling and you should be really, really scared if you see a child difficulty breathing and having large amounts of drool, unimmunized. Uh Normally what we call is called a sniffing air position. So they'll be on their all four stretching their neck, unable to talk, trying to maximize their air, air entry. And we'll see the thumbprint sign uh on the X ray and enlarged epiglottis, sinois again is prearrest state. And if you see a child with epiglottitis, most important thing that I want you guys to know is keep them calm because if you start panic, panicking, that transfers to the parents and then the child starts panicking. And obviously when you panic, your breathing rate goes faster, your heart rate goes faster and that makes things much, much worse. So important thing is for you to keep calm. If you notice something calmly, step outside, leave the room, ask a registrar to come in and then they'll escalate it further. Yeah. So initial theaters, we need to transfer them to the theaters for uh to anesthetize them and intubate them because the airways can close almost suddenly. So it's better to do it in a controlled manner rather than it happen suddenly in the cubicle. Once the airway is secured and everything is comfortable, then you start with uh taking the third generation cephalosporin doing the bloods and things. What should not happen is you are suspecting that a child has uh epiglottitis and you start doing bloods and you start doing swabs because all those things will just agitate the child and make things make your life much harder next coming to asthma. All of us know about it. It's very common in Children. Signs of severity include tachypnea, subcostal recessions and tracheal tongue. So when you see tracheal tongue, you should be again, worried that the asthma is quite bad use of accessory muscles, prolonged expiration. Sometimes, what you'll see is that you won't hear any wheeze, but that is because there's poor air entry. So how you differentiate a well child from an unwell child who's just not breathing well is look at the expiratory phase. If they, they have a prolonged expiratory phase, then again, that is a sign of a worsening asthma cyanosis and altered levels of consciousness. Classical reasons that I'm sure you all have heard of and for a child under the age of five with suspected asthma treat based on clinical judgment and review the child on a regular basis because sometimes you need to top them up with salbutamol. Sometimes you need to give them prednisoLONE, sometimes you need to go even higher exacerbations are treated with spacers or nebulizers and you can also give them ipratropium of magnesium sulfate if they are deteriorating short, uh course of oral steroids is sometimes indicated in severely ill patients. And sometimes we also if they are not improving, give them aminophylline as well. So now this is the sound of be. Ok. Mhm. Ok. Good. Yeah. Mhm. Oh, man. Uh. Oh. Mhm. Mhm. Mhm. Uh What else? Yeah. So in an early asthmatic person they might just have cough or breathing uh slight breathing difficulties but no proper wheeze. Ok. Ok. Ok. Ok. Yeah. Ok. So Mhm. Mhm. The. Mhm. Yeah. So I'll just put the part play. Ok. Mhm. Mhm. Mhm. Yeah. So, this is the part that we should all be worried about and should keep in our mind. So, if you see a child who's otherwise, well, has a history of asthma. Currently, you auscultate, you can't hear much. He's crying anyway, but you don't hear any wheeze. What we sometimes do is we just give them a trial of salbutamol. So you give them some salbutamol. Wait half an hour re auscultate. That's when you start hearing the wheeze. So basically, the child was so unwell that there was no air moving to the lower airways and that is why you could not hear the wheeze. It's not because they were well. So this is just something to keep in mind if a child is asthmatic was wheezing and suddenly has stopped wheezing, make sure that it's not that they are going into arrest. Yeah. Next coming to bronchiolitis, very common. But I feel like in the next five years, probably we'll stop even talking about this because loads of wonderful vaccines are coming around. So basically, it's a viral infection of the lower airways caused by R SV, common in kids between two months to six months. Uh Sometimes it goes up to like 1 to 2 years. Disease progression is one day, two days of Coryza increased work of breathing, nasal flaring. There might be even sometimes apnea and difficulty feeding chest x-ray is usually normal. You will not see anything. Sometimes there's hyperinflation, but that's it. And there is no as such treatment. Sometimes people give salbutamol but that does nothing. So there is no point in giving salbutamol in kids under the age of six months. The reason being uh they are unlikely to be asthmatic simply because they don't have the receptors for it. So asthma is usually a diagnosis of a later age of 2 to 3 years. And if you have a child who, even if, if they have a wheeze uh giving salbutamol will do nothing because they have not yet developed the receptors for the salbutamol to work. So the only thing you are going to do is cause lactic acidosis and uh tachypnea, uh tachycardia, sorry. So, hence, so like usually for bronchitis, you'll see anybody who's a respiratory consultant will say just give them oxygen, do not give them salbutamol. Sometimes you can do it in older Children. A trial of bronchodilators and steroids. IV fluids should be given if they are not feeling well. But basically, it's a thing of waiting and watching and helping their body develop immunity. Next is pneumonia. Auscultation signs are subtle x-rays usually needed to confirm this. There are multiple causative organisms here. Staph aures usually see in kids under the age of five mycoplasma, sometimes under the age of three, the all these other viral causes and treatment is antibiotics based on the guidelines now, limping child here as well. So, if a child presents to you with limping, we need to find out. Is there a history of trauma? I'm sure you guys must have heard of this before. But if you are seeing uh, limping or a joint swelling in a child who is immobile, you should be really, really worried if it's a child who is, I don't know, three months of age and they have a huge swelling or deformity of the lower limb. Be really worried. It could be, it could be something else because they should not be having a fracture in a three month old child who's just lying on the court. Right? So find out if there's a history of trauma, if there is a history of trauma, have a low threshold for same day, x-rays consider referral obviously to A&E and then consider child protection in cases of younger Children. If there is no history of trauma, assess them based on their age and their history and examination, right? If the child is well, symptoms less than 72 hours, they're mobile but limping, they're able to walk around no red flag signs, then we just give them likely to be transient sinusitis. Yeah, give them advice to give them analgesia and give them safety netting advice about SUFI and low threshold for same x-rays and review in 48 hours. If the symptoms are more than 72 hours, no improvement. Despite analgesia, then you need to have the amber signs in place and then need to escalate it further to the at signs of septic arthritis, temperature of 38 5, unable to weight, bear extreme pain on even passing movement of the joint. Then you're worried about septic arthritis, IV, antibiotics. Maybe a culture from the site if it's oozing and take it from there. Signs of malignancy. If they have fatigue, anorexia, weight loss, night sweats, child, waking up at night could be signs of tuberculosis, could be signs of malignancy and you just have to escalate it further. Yeah. So how we classify? Limping is based on the age of the Children. If it's a child, less than three years of age, the most common one are septic arthritis. They are usually are common in Children under the age of four pain, difficulty weight bearing joint is hip joint is sometimes flexed and abducted child looks unwell. Even passive movement is extremely painful. It's a medical emergency. Yeah. Uh sometimes there might be small amount of passive movement in femoral osteoarthritis. But the problem is it can then extend to the joint. Transient sinusitis is less common. Sometimes there can be fractured, there can be toddler fracture in any eyes. In three to age 10, transient sinusitis is the most common cause usually caused after a viral illness. So they'll have the viral illness, they'll be fine and then they'll develop the muscle pain and sometimes it's uh most commonly it's seen in boys between the age of 5 to 6, managed with analgesia and rest. Sometimes you see per s disease as well. Uh between the age group of 3 to 10, again above the age of 10 years. Septic arthritis is common. And then you also see something called SUFI, I have seen a couple of them. So they'll be usually kids who are slightly large overweight and then they'll suddenly develop this pain. Usually it's bilateral. Most commonly in boys, seen usually as uh as knee pain and you have a look at the X ray. It's quite impressive. Literally, the upper uh the femoral epiphysis has slipped off and you can see it and they need urgent treatment and referral to an orthopedic center. And lastly, at any age, they can have malignancies, they can have uh hemophilia which can cause a sickle cell which can cause the sickle crisis. They can have due to neuromuscular problems like cerebral palsy spina bifida. This can also affect the limb and finally, inflammatory diseases can be there, which are a little bit rarer. And these are the coach's criteria which are something that we use. So if they have a fever over 35 unable to wait there, crp over 20 or white cell over 12. So based on this, these four criteria, we divide them. How likely is it that is it septic arthritis? So, if they have one criteria, any one of these, it's a 3% chance. But if you go up, if there's four, it's 99% chance. So you kind of weigh your odds and just take it from there. Uh, because you don't want to sell, uh, send the child home who has septic arthritis because they can deter it quickly. So you just assess accordingly next injury and trauma. Uh, as we all know that it varies based on the age. So as we can see here, it is quite clearly illustrates from age zero. So then they are just newborns. Most common, commonest cause of injury is a fall and as they get older, motor vehicle accidents and penetrating injuries kind of take over. So fall is the biggest cause in this age group and it changes as they get older. So there's a pediatric Glasgow coma sale. So as you have the G CS, it's slightly different because you need to modify it because Children can't speak. So you have to use other ways to kind of assess them and make sure that they are fine any score like I think I'm sure you guys know this less than eight intubate. So any child having a score of less than eight needs to urgent attention needs intubation. Yeah, so this is how we go about it. So uh the eyes can be 1 to 4, does not open the eyes open to pain, open to speech, open, spontaneously, verbal, no verbal response. B uh two is inconsolable and agitated, inconsolable and constantly moaning is three cries, but controllable is 45 is oriented, well oriented and for motor responses, one is no motor response, two is decerebrate, posturing. Uh three is decor to get posturing. Four is withdraws from pain, five is withdraws from touch and six is most spontaneously. So based on this, you do it and you have a GCS score based on that, you can assess how severe is it. Do you need to involve uh the trauma center and transfer the child? Yeah, always, always remember whenever in doubt, just go with your systematic assessment, you'll never miss anything. Make sure you have seen the complete assessment and done A to E management. Yeah, get senior help early. No pediatrician will ever say why do you bring me into this room as pediatricians? I feel like I like to believe that we don't have that many egos or anything else like that. So it's kind of a vertical hierarchy in the sense that if you're worried about a child call a senior, if you can't listen to the chest call, a senior, if you're worried about something like an N I pediatric trauma call, a senior, right? Crucial to learn the differences between pediatric and adult. CPR A LS and S are very good sources. There's loads of differences, but the important thing to keep in mind is in an adult. Uh you do a thirties to two versus in child, you do uh 15 to 2. Yeah, major hospital, uh major trauma protocol. Every hospital has this as well. If you're concerned just double two, double two and mention the location because sometimes people just says double two, double two, say pediatric trauma and hang up, the team doesn't know where to show up, right? So always double to double two and say I'm in the pediatric ward, I'm in A&E I'm outside the hospital wherever it is double to double two and let them know. Obviously, if you're outside the grounds of the hospital, then you call triple nine. And finally, an important note of something I feel like it gets missed is any eyes very, very important. Every parent we'd like to be, we'd like to assume that every parent has the best interest of the child and heart. But sometimes things happen and any eyes do unfortunately happen. So we need to always be a little bit suspicious and cautious when we are examining the child safeguarding is an essential component of any pediatric consultation. Even if a child is coming with tonsillitis, if you are suspecting something else, is the child withdrawing once the parent has left the room, is the child talking more anything abnormal unusual, make sure that you have a safeguarding assessment in place. Yeah, things to look out for bruises, ving shape like if you see a bruise in the shape of a hand identifiable, implement any linear scars, anything like that cluster bruises and and always, when examining a child, I've seen many people do that, that when they examine the child, they just put the stethoscope on the clothes, make sure that you remove the t-shirt and the shots. When you examine the child, even open up the nappy because sometimes these bruises and these marks are hiding below the places to see which you normally see and obviously bruises you see in a child who cannot mobilize, that should have your uh red flags going up lacerations, highly suspicious lacerations in Children who are nonmobile lacerations around the face around wrist and ankles. Think about potential like a terrible injuries. Again, a common thing that happens with these Children is the injuries of the sole of the feet. Normally a child should not be getting injuries of the sole of the feet. So have a look there and make sure everything is fine injuries with sharply delineated waters and multiple fractures. Parents coming in multiple times and every time it's a different story, but it's a bit unusual for a child to keep having injuries. So if they're having multiple fractures, metaphyseal fractures, spinal fractures or if even if nothing else, but you see like, oh, they were waiting in the A&E and then they've left. Even that is something to be suspicious of. Why are they DNA? Are they not appropriately concerned? Why have they left? Is it a language barrier? Is it a cultural thing? Or could there be something more malicious differentials in any eyes. We don't want to straight up accuse a parent of any eyes. So Genis imperfecta, if there's a family history of fractures, siblings with getting same things might be. It's that maybe coagulopathy, maybe the bruises that you're seeing is because they have an undiagnosed coagulopathy. So make sure that you have those in place and how to deal with N I if suspicious always escalate with seniors, there are loads of resources in place in every hospital, in every trust, there are social workers, there is CAM S workers. Maybe those injuries are self-inflicted. So yeah, and injury and associations like red and Saint Giles really help out with a troubled youth and the choice of the intervention is based on the assessment of the child and these are the references. Thank you so much. I stopped sharing my screen now. Yeah. Thank you so much. Any questions, all questions? Yeah, I left last, last bit of time just for open for discussion. So anything you guys would like to discuss, any topic you would like to further discuss or anything else. A couple of things I could not add on to this uh presentation. I was trying to keep it brief is again, undiagnosed type one diabetes mellitis. So that is again something you should have in your mind because it will be a child who will be constipated, vomiting. So always make sure that you do uh fingertip BM and uh urinary dip just to make sure that you're not missing out type one. Diabetes. Melius. Ok. Yes. I mean, it depends. So sometimes they ask, I feel like having a rough idea really helps. So you should know what a normal vital is for a neonate and that how it goes further. I feel like what I used to do was like, know what's normal for one year and say no, know what's normal for two years and five years. So you have a rough idea if something is grossly abnormal that you know what it is. I, I do not have a handout. We can give you the print out of the presentation, uh, like a recording of the presentation. The, uh,