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No, no. Uh And we are going to carry out this presentation because last time we agree that we will finish the cases which is like a virtual simulation. So we're expecting um uh those who are present to participate at apologies because I have a viral infection. So uh this session, we are working on identifying the sick child and we have used the approach A B C D E which is A is the airway, these uh effort and efficacy of the breathing, see circulation as well as hydration. The do not forget the blood dolichos but as well. A neurology assessment including after Andy is exposure, temperature skit and other examination. Others, they include abdominal examination and E N T. So uh we worked on these cases to here and this is the next case where if you ask me questions had a will be uh supporting, I will ask you a question. So you are uh the doctor in any or in the Children as aspect to it or the G P the family doctor. And you have a five year old boy who I was brought before his, with his family because he has sore throat and a fever, but they're very concerned they brought him because he was phytic. So, what, what, how would you, um, take a brief history and assess this child first? Um, I guess when I stopped it I can't hear very well. Sorry. Uh, okay. So the he has been fitting now, they just live across. So he has been, was probably fitting for about 56 minutes. He had the fever for about what the complaining of his sore throat for what day. So if there's anything in the chat, I can't see it. So I hope that had a will be able to read it. There's nothing in the chat. But if I might suggest that people who want to speak up, raise their hand first. So we don't have people talking at the same time. Uh or if you want to write in the chat right in the chat and I'll read out. So you have a child who's fitting in front of you. How would you assess this child? Yes. You think the A B C D E approaches as it was previously with a child? This might be fitting. The problem is the willingness, music is the challenge. We will enforce Feliz with assistance or normally is the breakfast is to die of. Also, this is second uh just a normal that fit. So for one reason or the other, I can't hear you very well, but I think you're going through the A B C D. So, seizure or fitting is one of the issues that can co provides the airway, especially if the child is um biting their tug or vomiting. So we have to be careful with a and check whether the airway is painted. That's the board. As a junior doctor, you will be calling for help immediately as you progress in assessing this child. And uh it is, you know, very reasonable if you have oxygen to make sure that you apply the oxygen. But remember if the child is vomiting, if you have a mask, that makeup provides the vision. So uh in this child, the airway, the child is fitting and he's closing his uh teeth and you, you can see that he has got like purple discoloration. So you have applied a basque with a re breathe um and you are cesic now be so when you are sick beat, um you're couching the respiratory rate, his respiratory rate is about um 25 the saturation monitor where you put it is about 90 to 91. So if you applied oxygen and you're looking at the response and Editori is equal. So that's sort of airway at breathing. Now, coming to see um any questions that you would like me to upset about? See we'll check the BP. Uh C is for secular tresses, you Jesse for circulation, get you the BP. But what can you do? Like a time capsule? Logical time because that pressure would not be able to get a patient. Uh Yeah, so we do the cabinet full time in the center over the sternum, not referral and the capillary feel time is about two seconds. It should be less than two seconds. So that's acceptable. You take the peripheral uh pulse in a four year old. You can basically uh take the radio or take the break ill or, or even the carotid or one site and his heart rate is 100 and 40. Um Then uh you, you have the BP will be measured. Um The hydration status, you can check that. But at the moment, you're worried more about defeating at stopping the fitting. So if see, it may be the appropriate type two, uh put that access or IV access, uh check some of the bloods if needed immediately. What other questions you would like to ask the family as this child is fitting and you're trying to sort out the treatment. Is this the first time the fitting has agreed? Or this has a good visual is um is once a, once the fitting, ossential has agreed is the chance it will occur again. So you'd like to ask, is this the first time or good? So you're asking, is this child who has a known epilepsy and he just had a fever at that triggered and he had another seizure. Uh You would like to ask if this seizure is like on all sides. Call it generalized tonic clonic, clonic is being like stiff, clonic is the movement, chronic movement of the upper limbs and lower limb or is it focal? Is it one side? Um So is this the first time? Is this child having epilepsy? What type of seizure? And you asked about the duration? So the family tells, you know, this is the first time it doesn't have a diagnosis of epilepsy. He was complaining of the sore throat, he had a fever and suddenly he had this generalized. So all body tonic. So he goes stiff and then there is this jerking movement of the upper limb and the lower limb deviation of the ice to one side and clinching of his teeth and he's four years old. So you are reaching d now. So you've done the cannula, someone took the blood they take for you the blood sugar and the blood sugar is 4.5. So that's normal. That is important because Children can fit if they are. Why am I here and paying attention to blood to the cause? Because of the black poodles would be less than uh blood sugar is very good because a sick child who may not be eating can be hybrid like this can have a feature. So the seizure can be a presentation of hypoglycemia and to stop the seizure, we need to give the blood. Yeah. But in this case, that's not the situation. The child blood glucose is normal. So we have ruled out hypoglycemia. So now we are on d we have the child who's fitting. Now approaching 10 minutes, we need to treat the seizure. We are looking at his pupils because that's part of the uh and they are both equal, are reactive because if they are not equal and they are not reactive. We were worried that the cause of the seizure is how many is actually urologic pupils? Yes. So something central nervous system. So we were really worried about something there, but that's not the case. We have to generalize, it's not focal. So um so far we have a child who seizing and having fever and was four years old. So um just as we're approaching 10 minutes, when you are assessing the child, the the seizures started to, you know, like stop seems like it stops fitting. So you're not going to give medication. But what should you, what should we usually prepare if you want to um treat the seizure? Do you know what are the medication that we use? We use dice upon. But uh so the name, the name is Benzodiazepine. Yeah. So we use uh diazePAM and that used to be given rectally. Now people use midazolam and that can be given in the back alley me Koza and we use LORazepam which can be given intravenously. So, Benzodiazepine can be given. There are different doses. You have to look at the guidelines because it's different by weight and age. DiazePAM usually give a rectum, midazolam, vocal and LORazepam IV, the advanced pediatric life support advice that we should use this twice only we can give two doses 5 to 10 minutes apart. The problem was giving benzodiazepine. Uh the side effects. Do you know any of the side effects of benzodiazepines? So one of the important respiratory, yes, respire it to me because it's respiratory depression and you have to be careful when you are giving it. So you have to give first of all the correct those you have to wait for about 5 to 10 minutes for it to see whether it's acting or not. If you want to give the other one and you are a junior doctor, you have to make sure you have a senior colleague with you because you don't want to give the other does. And then the child is, you know, you need to support their oxygenation or their breathing. And you know, you need the right expert with you. But let's talk about this child who's four years old who have fever, sore throat. I'm fitting what could be the diagnosis. So when you reach the, then you started, you know, assessing d he stopped fitting when he went to e he still have a high temperature, you have looked at the skin, there is no rush. So what do you think? Is that the diagnosis in this case? Do you know about the presentation of fever and, and fitting what could be the differential diagnosis. I don't know if I'm thinking rheumatoid and see if a light. So when you have a fever and a seizure, you have to look at the serious illnesses and you have to look at other common problems. So the serious illnesses is CNS infection, whether it's meningitis, whether it's in careful itis in other countries, it can be scribble malaria. Yeah. Um And so that's one of the things that you have to rule out when I said there is no rush, you can find purple, ink crush, take a rush that that goes with meningococcal sepsis. Uh the causes for men in judges and, and cephalitis can be viral or the cause of meningitis can be bacterial and that can be sometimes determined by the age with the common organisms. We have fever. So we're thinking about infection but we said we have to think about sometimes very rare, you know, like if you have focused seizure and fever, thinking about is there an abscess or this child is sick? You know, immunocompromised, there any reasons to make them having, you know, very serious um uh sort of certain central nervous system complications without fever. It can be epilepsy as the cause of the seizure. It can be due to electrolyte imbalance as we have mentioned, hypoglycemia. But as well, if you have hypocalcaemia, hypomagnesemia, that can cause it sometimes if you have a child who severely hyponatremic or child to have a significant hypernatremia. So, with electrolyte imbalance, um and sometimes with head injuries, whether that nonaccidental or accidental injuries. So you have to think about it. But when you have a fever, you have to think about infection. In this case, this is a six old boy who was well before just had a sore throat. There is no problem with his development. He had the seizure which is generalized, all body tonic clonic seizure for 10 minutes and stopped. So, do you know of any diagnosis? Have you heard about febrile convulsions? Yes. So the bride convention can present, you know, between people say six months to six years. There are different ranges. Um there's usually a family history so you can ask them and they can say yes, his dad or his mom when they were younger, they used to have a fit when they have uh fever. Um the child usually is a well child know developmental uh normality. These uh this usually is uh you know, uh less than 15 minutes, it's usually generalized and usually the child recovers well. However, if it's not the typical, it's longer than 15 minutes, it is on one side rather than the other side. It is very frequent, then the child will have to be seen by the neurology because they have to think and consider epilepsy. And Children who have epilepsy when they have fever, they have a low threshold to have uh seizures and fit. But in the child who is presenting with the common presentation in the normal age range with no other core mobilities is for bright convulsion. All we need to do is um um teach the family about the bride conversion and advise them about 30 state. There is nothing else we do. We don't give any anti epileptic medication. The treatment of fever with paracetamol, I Praveen usually doesn't help. Usually the child is running and then the second, you know, next second he is fitting, it's usually following viral infection for the upper respiratory tract. Do you have any question about this case? Are you happy with the approach this one? So if we move to the next next patient and whether you can see it or not, the seven year old girl, I was having a meal outdoors with her family. Suddenly she complained of a funny throat. She had swelling of her ears. She developed a rash, started vomiting. Are coffee. How would you approach this patient? I think I have a uh a preliminary diagnosis. Probably do with ABC A again, maybe. Okay. So Stevie, uh she might have ate something which would she might be allergic to good. So first we checked the patency of the airway. Can she breathe or she's finding difficult in building? Let's try that or something like X slash. So from the story, we are worried that she may have um have an allergic reaction to something she ate or she's sitting outdoor, she may have a bee sting or a wasp sting. Okay. So it can be, uh, either some 68 or something else. Now, we are worried about airway because if we have a G O diva, which is swelling from the release of the history that Brad Ikay did, that would lead to airway compromise as strider. So we are looking at the swelling of the lips, but we're looking at the swelling of the tug. Um The U Villa at her voice, is she able to swallow? Is she able to talk? Is there any change in her voice? Uh Is there any uh inspiratory Stridor? So that is a what about B breathing and that she is able to breathe whether he is breathing normally or he's trying to uh news access, cervical cervical access in your system village is trying to be heavily. We have to find them. So the breathing would be affected if you have an allergic reaction. So she can be the kid Nick that's breathing fast. As you said, she may be using accessory muscles, she might be hypoxic. There may be bronchospasms. So we may hear expire a Tory wheeze. So that can be a presentation of systematic allergic reaction because we have mild, moderate allergic reaction and we have severe allergic reaction which involves more than one system which we call anaphylaxis. So in this case, if this patient is showing these symptoms will be worried that this is anaphylaxis. Let us move and then we take her oxygen to make sure that she's not hypoxic. Let us move to see, uh, what is the important of assessing? See in a child with a severe allergic reaction? Whether she's not getting simunek, the, the street let flow is not competent. Okay. So, Hannah, I can't see if there are any hands I'm, you know, dependent on you. No, that's uh that's gone. So the see, I think, I think it's just to assess if the patient is going into shock. Some example, that's a good question. So we are looking at circulatory failure because we will have wide, you know, like spread of um you know, uh distributive shock of fluids um outside of the intervascular space. And so the trial will be Turkey Kartik, maybe hypotensive. This is really serious because if you remember when we discussed earlier, we said hypertension is a very late sign in Children. So if we have hypertension, we are very worried that the child is pre arrest because Children usually able to preserve their BP by peripheral visa restriction to the last moment. If they count, it means that they're losing this and we have to act immediately, the capillary refill type will be, will be prolonged in this level. We have to have an access, this would be what we call a critical venous access. So a cannula or interosseous because we need to give what we need to give at this stage. Sorry, anna tropics can Leone and see Multilingual tropics until 19 expending or okay. I've been efforting. Ok. Epinephrine or adrenaline. So what we need to give at this stage are too many things. Okay, adrenaline or it's called epinephrine. It depends what you're practicing. We need to give fluids, isotonic fluids. So we need to give the epinephrine to make sure that we maintain the cardiac output. We need to give fluids to make sure that there is enough, you know, intravascular restoring the intravascular volume. We do not give anti histamine or steroids at this level because they're Axion is not life saving. So there has been an update regarding anaphylaxis treatment. The priority is for what did I say? Now, the prices are for two things. What are they uh normal saline? So 10 mils EKG or if you have heart mill solution and uh epinephrine or adrenaline repeat that again in the treatment of severe allergy and anaphylaxis. The priority is for adrenaline and normal saline and you should continue giving the adrenaline if you're giving it, I am until you are the child is in hospital. And there are intensive ist and their senior colleagues usually um we can give a drilling I M and there are different doses of 100 and 50 microgram, 305 100. I don't want to go into a lot of details. But what I'm trying to say that the priority is adrenaline. You can give it I am, you should repeat it if you know the patient is not improving. You have already called for help earlier as a junior doctor. If you have a canula, you need to give apartment or normal saline 10 mils per kg and you may need to repeat that do not waste time by trying to find anti histamine e and hydrocortisone. Um These are going to come second, do not waste time by giving salbutamol before that drilling. So the priority is adrenaline fluids, you may repeat the adrenaline and then if you can give the salbutamol with the oxygen, uh and you have to get the child in the right place. Do you have any question about that? No more? Okay. So if we move on to the next scenario is a 10 year old boy presented vomiting and having diarrhea and they noted blood in the diarrhea. He cannot remember when was the last time he passed student? And he has developed a rash in the last 12 hours. So what is your approach for a child with vomiting, diarrhea, reduce urine output and skin rash? And I can see there are some comments on the chart. Yes, that was just the same answers that we already given. Great. So what is your approach? This, most of these cases are common presentation. We need to talk about the common presentation and the complicated part as well. So, tell me what is your approach? We do a aggressive uh fluid intake, fluid IV because he, the patient is severely dehydrated. Like I'm not going for the ABC because I think it's an emergency case, vomiting, diarrhea, diabetes, blood to produce, you know, so aggressively wouldn't take should begin. So we need to go and I agree with you that you have concerns, but we need to go. A B C D doesn't take a long time and you need to ask some questions because then you can make a good decision about what you need to give. Is it fluid or something else? So obviously, you're going to ask that the family of the child about the duration of the vomiting, whether there is violent, the vomiting, whether there is blood in the vomit tick because are we talking a blood diarrhea or we're talking about childhood bleeding from other sides as well? Then you have to confirm diarrhea, the frequency of the diarrhea, the present of blood ab you kiss and reported to check whether the child the thirsty is he lethargic? Is he active? And the unit output, you need to clarify which skin rash when you're examining the child because the vacuum popular brush can be just a viral infection. But Patiki eye will make you worried in a child who has blood in the stool and then he has pre K you are worried about something related to you know, hematology and coagulopathy. Okay? We will ask about fever because if you have a charge with fever or vomiting or diarrhea new that you're thinking about effectual cause as well. And you need to set the stool for biology and for bacteriology, you need to know whether the child has been traveling abroad and came back. And you need to know whether they went, for example, to a farm and they have eat it outside because you're worried about equal like enteritis because it can cause uh this presentation. Uh So it can be gastroenteritis with complication and you are worried about that. So if you have a child who has been traveling abroad and came back, you would be worried about which type of a try tous of legendary this could be. And did you. So because you're on the kitchen, it would be radicular Asus or something effective tie for you. Like I was giving a blind uh primary diagnosis such as very close or uh something in the typhoid fever. So that's why if the child has traveled to an area where we have typhoid, but it can be equal light if the child is really 60157. Have you heard about equal? I 0157? Yes, ma'am. Um So this is can cause serious uh this entry um blood in the stool or itself can be presented because by Kabila factor and other viral uh you know, gastro tresses. So we don't get worried about it. But what we are worried about here that the child has reduced urine outputs of possibility hydrated and has got P T K. So we are worried about that disgust row tratos is complicated. So just like um covered sort of gastro tratos, it Children. So if you go through A B C and D, so yeah, take me through. So A you will be worried about the vomiting, make sure that the child aspirate uh spirit and then you go to would be um uh see the respiratory rate, the saturation, the work of breathing. Then you go to see here is it's really important because you're assessing the circulation, cold hands or feet, thready pulse, uh the BP, the heart rate and then the blood glucose. Because if the child is vomiting, you're having diarrhea, not keeping anything. You need to put that access, try twice for a carrier. If you fail that you go for an eye. Oh and you have to have electrolytes. Um check the renal function, test, check the full blood count, the platelets, check the coagulation because you have blood in the stool. And at this level, if you feel that the child is significantly dehydrated, you will give normal sal I 10 bills per kg. If you feel the child's hypoglycemic, that is blood sugar, as we have mentioned before, less than 2.6, you have to give 10% extras polar bolus and then you will go to uh is a child alert. If the child's dot alert, you will be concerned about dehydration or further complication. Are you concerned about the urology? You have take the blood sugar cause already and then in the exposure, you will check the temperature and you will check the type of the rash which is this cases particular rush. So in this case, the child has got what we called H US. Have you heard about humility, Keramik syndrome? Yes. Others. Have you heard about her ability? Curx syndrome where you have equalized 057 that will lead to blood in the stool, affect the platelets and may affect the kidney function. It's a very serious complication. The patient, they did a vision to the intensive care. Some Children may even develop renal failure requiring dialysis. So what we're trying to say you have gastroenteritis, cover presentation, know dehydration or rehydration at hope with diana light. Fair enough. But you can have Children with gastroenteritis with complication, whether that's because of the organism or because of the delayed presentation or because they did not receive the right advice about oral hydration at home. You have to assess A B C D and their hydration status and make sure they're not hypoglycemic. Is there any other combat or any other question? No comments in the chat. Any question about this case before we move on love with his. So we have a 14 year old girl presented to your uh your the family doctor. They said she's lethargic, always thirsty. She's now vomiting for the last, uh, two days. The family felt that in the last 2 to 3 weeks she has been losing weight. What else in the history you would like to do? And how would you assess this child? We would like to know where your, the last two weeks that she has showing the symptoms where she goes in the last two weeks. Did they get it? They sent out some tears other than what they are like, I was uh my date so she has been methodic. She has been eating, she has not been off until yesterday. She has been thirsty reaching a lot of fluids. Um They noted that she's losing weight. She wakes up a tie to go and pass your it in the last two days. She started vomiting and she became more and more lethargic. Any other question? Any thoughts? Do you want to go through A B C D early Urea White night Doctor Ugo uh with paycheck, but she has been vomiting. So you can see the vomit, you know, in her clothes when you go to be, she is breathing very fast and there is a funny smell. Her respiratory rate is high. Her saturations are 92%. It rube just okay. Air entry is equal bilaterally and there are no UN sounds. So this is a A MB, any thoughts so far or should we move? To see any comment on the chat die, avoid someone has given suggested diabetes suggested what diabetes? Perfect. So we're moving to see we are worried and we are looking at her heart rate. She's tech A Codec. Her heart rate is high, her hands, her feet are cold. Her capillary full time is 3 to 4 seconds. The normal Capitol Hill type is what is the normal time for the capital refill time should be less than two seconds. Uh 3 to 4, we're checking her BP, it is low. So we try to put that access, take some bloods, give herself fluids. So, recheck D she is very tired. She's answering you but she is very tired. Pupils are equal and reactive. There is no neurological deficit. This is important and we'll come to know why later and we're checking her blood sugar and her blood sugar is 23 and the normal should be around seven. And when you check hard Ketos in the blood, they are too. So this is very high. They set some blood for the gas uh severe uh sample and her ph is 7.26 with P CO2 of uh six or 5 ft and her basic cess is minus 10. So what do you think she has got? Uh it's somebody has suggest to diabetes, but we could also be ketoacidosis. So it's together word called diabetic pediatric residency. So, hyper July Syria high blood ketone low blood dolichos, low blood ph as he does is so low ph below 7.3 as he does is high basic cess a low by carpal. It. So this is a metabolic as he does is high blood bellicose, high blood key tote. So the combination of all of that, that this child is an emergency. She have hybrid Liffey Bia first presentation of diabetes presenting with DKA, DKA, the very serious complication because we need to treat these Children carefully. They are significantly dehydrated subtypes. We need to rehydrate them IV but we have to do that very carefully because if we don't do it, uh we will have because of the hypoglycemia, we can have a lot of fluid going into the cell intracellular causing cerebral I deba at that can cause complication. Usually there are guidelines for treating deep key a the line of management are treating the dehydration with fluids but carefully treating hybrid Juris IBI A with Isaly refuge in. You have to calculate that, monitoring the electrolyte imbalance and monitoring the neurology of of the patient. So that the patient is developing any complication like cerebral edema, you act immediately. You have to remember that when you give insulin, you can have the insulin will push the potassium towards the cell. Is it it you know that the insulin will push the potassium inside the cells? You know that. Yes, yes. So there is a possibility of hyper Collyrium with the dehydration that can be issues with sodium. So we're not going to discuss DKA here, but it's reported if you have a child who's presenting thirsty with history of polydipsia, polyuria, polydipsia as drinking plenty of water fluids. Polyuria, passing significant about of Europe and weight loss who is presenting dehydrated and the dehydration is severe that we follow the guidelines about hydrating this patient carefully. So we don't push them into slippery diva. We treat the hypertrophy be a with Israeli refuge in and we monitor the electrolytes and we monitor the neurology of the child because they can develops liberally deba the cause for that will be the imbalance between the hyperglycemia, the water going into cellular, the sodium support and the movement of the sodium intracellular and between extracellular space. So I will advise that you look at the local guidelines where you work for the treatment of DKA. If you are suspecting a child with A D K, you have to call for help early because you don't want to get into morbidity and mortality. If you are treating the child with excessive hydration or you don't pay attention to the electrolyte imbalance. Is that clear or is there any question uh at this level? Last two weeks? So the last one. So we have a 16 year old boy who is known to have lymphoma on treatment. The child has got a central line. The family called to say the child has got fever. Should they bring the child to the hospital or just give the child paracetamol at home and watch. Okay in pretty hostels. Why? What are your thoughts? So they're telling you the chance eating is drinking a little bit. He feels under the weather but no vomiting. Uh, but diversity step, Richard is 38.5. What are the risk factors? Last time? We spoke, we talked about some risk factors that make us worried about certain type of infection and fever in specific groups. Why are you concerned about this uh young person? There's a possible chance he might be immunocompromised accents. So he's a child who has got malignancy was having chemotherapy. So he's possibly immunocompromised. So we are worried, what else? What is the other risk factor? Secondary infection? Might a girl so careful you would not bring him to the hospital place, know where he was going up. Other other factor that's written there is another factor that worries us when we have fever. Mhm. Yeah. Uh informa. So the riff oba at the therapy or radiotherapy, we talked about that. What else is the risk factor? What does this child have? He had a possible chance of Epstein Epstein Barr Wells. He has a, he has a foreign body. He has a central line. So the central line can be a source of an entry for infection if it's not handled properly. And so central line infection can be the cause of sepsis. And therefore we need to see this child. We need to examine the child. We need to send a full blood count blood culture, preferably blood culture from the central line. And we need to treat the child until we get the results. Because if there is a blood culture that's positive from the central line, we have to remove the central line because this frontal line is a source. Now imagine it like a busy place where there are bacteria hanging there and spreading to the whole blood. When you say central line, it's a a line that have access to a central vein. So if you have a group of bacteria growing there, they will just go everywhere and the child will develop sepsis or even can develop fulminant, you know, infection uh and even like endocarditis or other uh sort of infection. So you have a child who has got malignancy, there are a chemotherapy, this is a risk you have any child to have a central light. This is the risk. It's a foreign body. Foreign bodies are a problem because if there are bacterias, then the bacteria can spread into the bloodstream and could cause fault well sepsis and then it would be difficult to treat the child. So I think you had a very busy day today. Uh If you have any question in the next three or four minutes before we end. So, in the previous uh presentation with this presentation, we spoke about uh emergencies in pediatrics that we have a wide range of uh you know, presentation from the limited period up to, you know, young people. You need to know about fevering Children. You need to know about breathing difficulties about Children, presenting with gastro crisis. Uh These are the couple presentation usually uh you need to have a well structured approach about the assessment, A B C D and E. And there are a couple presentations that we we have presented today at the last uh session. Any questions in the chat? Huh? No questions in the charms. There is a website identified the sick child where there are videos about recessions uh granting um still destroy the um different type of particular rush peppery crash um death. This can be helpful. But obviously the best thing if you can, you know, try to be hard. So when are there are Children, you exhibit the, you know the Children. So you become familiar with what is normal, what is abnormal? It's a site with web site. Um And just either you find a sick child and I think yeah, you can, it's free as far as Alibaba. So if there are no other questions, I would suggest um that you make yourself very familiar with aesthetic Children. As I said, there are more or five topics that Bailey. One of them is fever. What is the respiratory problem? The other one is gastro problems and abdominal pay that you have rashes in Children and then you have a limping child. Was that one of the common presentation? And if you look at these five topics, they will cover most of the emergencies in Children. Okay. So I wish you all the best. Uh Is there any question about pediatrics emergencies? Uh do not hesitate to contact the team and I'm happy to answer these questions. Oh, someone has asked a question, doctor. Yeah. Where is edema seen in Deke? Deke a edema? Cerebral edema in the brain. So if you have rapidly give fluids and rapidly correct the hypercythemia, the fluid will shift um from intravascular intracellular in the brain and cause cerebral edema and the cerebral edema can cause complication leading to death. So this is why you need to watch the child carefully and assess their neurology when they have decay. They usually have special formula for how to give the fluids carefully and slowly and when do you to reduce insulin? So you need to see locally. What guidelines do you have any other questions? Um No, but people are saying thank you and the chance. So thank you. Thank you. Always know. Thank you for coming at all the best at any questions about emergency pediatrics. Please let me go. Let me know. I'm happy to come back and do any further sessions. So I will leave now at all the best. Thank you. Ok, bye bye bye. Thank you. Thank you.