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Please join the teams call at 7pm, not 6pm!

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The transcript call. If there are any issues, just let me know. Ok, will do. Thanks. And once I think so far two of you, but I will give it a few more minutes to see if other people join and then we'll go from there. Cool to the people who have joined. Uh, just giving it a few minutes, seeing if more people join and then just go ahead and start. Cool. So give me two more minutes and then I'll just start regardless all uh teaching. Cool. We'll just start. So, um, man, I'm a pediatric F four and six months in P ZD at Chelsea, four months in Peds Ward and just been ad hoc loing in Pedes across the board. So it's gonna be a relatively interactive lecture. So there will be a few points in uh why I ask questions. I just want you to just drop the answer in the chat and we'll go through the questions afterwards. Um, throughout the session, they will also the opportunity for you to ask questions. So if you just have a question and you want to chuck it in, just chuck it in the chat and I will answer it over at that point, I'll answer it all at the end. So feel free to ask questions whenever you want. There are no dumb questions and I'd much rather you ask a question or take a shot and go wrong rather than not asking and say silent. Ok. So um some of the memes in this are also a bit older because I gave this like two years ago. So uh apologies for that fine. So a lot of objectives, what you're gonna do is be able to assess the severity of common pediatric emergencies. So from an emergency perspective, you really have two kind of questions initially. First one is, does this person need admitting? And you usually answer that by putting them into a category of mild, moderate and severe. And that's kind of what you're trying to figure out with most emergencies. You're gonna know the initial management plan for all these emergencies. And I think for the purpose of your exam, knowing the initials will get you through. Um except DK A, I think you probably need that in a bit more detail. So we'll go with DK a bit more detail and last one is, yeah, you're gonna use knowledge, you're gonna smash your exams, you're all gonna do. Great. Ok. So uh next one, so I'm gonna read for the SBA and then you guys just drop what answer you think is in the chat. There's only like seven or eight of you so you can all answer and then be fine. Come on, an eight year old known asthmatic was at a birthday party living their best life or chasing their friend. They started to struggle to breathe. Child is crying with minimal tears. He's scratching his tummy and he says my chest hurts on exam. He's using accessory muscles when he's breathing. He's got a polyphonic wheeze and cap refill. Four cold hands. Heart sounds are normal. His observation is 8 9% oxygen respirate is 28. BP is 75. Over 45 heart rate is 100 and 35 T is 37.5. He's had two rounds of burst therapy with salbutamol with minimal improvement. What should be the next step in management? So give guys a minute to answer, just drop it in the chat and then I'll go through the question. So it's two people. Anyone else wanna try and hazard a guess that's fine. So the answer is actually be. So I've kind of misled you with this one a little bit because I gave you a known asthmatic and it's really easy that when you hear a wheeze not asthmatic that you just focus on that. But actually the hints I gave you here, this might not be asthma is a child crying, minimal tears. He s so that means he's a bit dehydrated. He's scratching his tummy, that's showing a rash. You don't typically get a rash and asthma, his cap refill is four and he's cold. So this kid is shut down and you've got a low BP. These don't come with asthma. So the point of this question is that when you hear wheeze and child trying to breathe the vast of time, it will be asthma, it will be induced. Wheeze. But keep adrenaline, keep, er, anaphylaxis in the back of your head. Also, thing to think about is often this happens at somewhere like a birthday party where they're exposed to a bunch of different sweets, a bunch of different snacks, a bunch of different things all at once. Ok. So going through anaphylaxis. So what is anaphylaxis? So the, the two things you 100% need to make diagnosis is rapid onset. So things are fine and they massively get worse. Anaphylaxis doesn't take hours or days. It happen immediately within minutes. And second thing you need either hypotension. So a massive BP drop or life threatening breathing. Either one is fine. You do sometimes get a rare BP drop without too many breathing issues, but you're going to need uh one of them, usually you're gonna get both. So you need rapid onset BP breathing and the other things you may or may not get, uh, but you'll typically get a rash, you might get some angioedema around the eyes, you might get some angioedema in the mouth and throat and also less reported symptoms. You get like a tummy ache as well. Ok. So can people drop in chat? How do you manage Anaphylaxis? So you've got AK front of view. Anaphylaxis. What's the first thing you do? Perfect. I'm adrenaline. If that doesn't work. What do you do next? Perfect. Yeah. So, and as you got it right. It's basically adrenaline. You just keep going. Adrenaline. You're right that you will need to get up and IV, but that can take a bit of a time to set up. So basically just keep doing the adrenaline I am until you get an IV line running. Ok? There is in anaphylaxis, there is no such thing as too much adrenaline theoretically, maybe you will never get to that situation. So all anaphylaxis they will get I am adrenaline. This slide may be worth taking a screenshot of doses. You just kind of need to know of your heart for your exam from what I remember in period. Very rarely did you need to know drug doses, but emergency drug doses are 100% what you need to know. So if you want to lose a mark on, so just make sure you memorize that for your exam IV fluids, you need to give them rehydration and you can consider bronchodilator. So if you've given the adrenaline, the blood pressure's coming up, they're seeming better, but they've still got a little bit of a wheeze, you can consider some albuterol things like that, but you're not always gonna need it. The other thing, textbook you're meant to do what's called a Marcel tryptase. So, it's basically a test that you in the acute situation will never actually use. It's for when they go to allergy clinic a few weeks or months down the line, you do it at zero hours, 1 to 4 hours. And then they do a baseline when they go to allergy clinic. Realistically, no one does it in practice every time I try to do an e everyone tells me because it's like it's a waste of money. We don't care about allergy can do it. But as per nice guidance, as per all the official guidance, you should do a Marcel trip place when they come up. OK. So if they've had two shots of adrenaline, I am and they're not responding, then you say they've gone to Refractory Anaphylaxis. That's the point we're getting our IV adrenaline infusion started. But again, in the meantime, if there's a delay in getting the infusion for whatever reason, it's just more I have adrenaline until you get that started. The other things. The reason this is all I put in, this is what A LS Guidance actually says you have to do. That's Resource council guidance, stuff like antihistamines, stuff like steroids. They are all actually now optional. A lot of people still will default, give it but they've taken it off the algorithm. One cos there are probably a lot of patients who can do about it. But secondly, they were finding that it was delaying, getting the important treatment in. So they took it off the algorithm so you can give it once the child is actually, well, that's not gonna acutely save them. So as far as the algorithm goes, it's just adrenaline and fluid may be bronchodilators. So next one durable six month old child is brought into A&E he's had three days of cris symptoms and can you all probably know but just for people who don't cise or cough. So crys is basically a fancy way of saying runny nose, three days of cries or symptoms, two days of cough, he's been feeling 50% of his usual. He's got three wet nappies every day, got no diarrhea and vomiting on exam, mild dehydration, noisy, mucousy breathing, widespread of prepi and wheeze present. No rashes, obs 88% respirate, 40 heart rate, 100 and 40 cap refills free temperature is 37.9. So in the chat, give it a minute or two and just drop whatever you think. There are no, well, there was the wrong, there are wrong answers, but there was nothing wrong with getting an answer wrong in a teaching session. So the answer is c so you're right, Paula. So this is a case of bronchiolitis and the kind of key thing with bronchiolitis is you're not really doing anything just going through the answers. Uh Salbutamol and Atrovent didn't really work. The reason being people used to say it's because they believe kids didn't really have the receptors before one years old. That's not true. They proved it. You do have the receptors. The bigger issue is in asthma. You have kind of free physiolog going on. You have the swelling of the airways. You have the muscles constricting and you have um mucus, build up in the lungs. The salbutamol helps with the muscle constriction of the smaller airways. The issue of bronchiolitis is basically all just build up of mucus and debris in the lungs. There is no real um narrowing of the airwave due to the muscle contraction. So therefore, you can chuck every bit of salbutamol in the world at them. It's not gonna make a difference because that's not what's causing that problem. Same thing with amen, that a similar thing. But again, we are not dealing with muscle contraction here. Nebulized adrenaline. They used to say that as a thing you can try and some people often do it in like a hail Mary type situation. It's really, really bad. Nothing else is working. But again, they stopped taking it off the guidelines because there's really no evidence for the ne adrenaline. Um, nasal suctioning is the right answer here because what I'm trying to get if this kid is very snotty and often in bronchiolitis, if you can get that suctioning done, you get that mucus out of their nose they will feed better reason being kids, they're so blocked up and you breathe through their nose when they're sucking on a bottle, they struggle to feed because their mouth is now blocked by this bottle or this tip and their nose is blocked. So you just can't breathe. So if you can clear out the nose to actually feed better and then you can avoid putting the you tube down the childhood antibiotic. Right now, there's no real evidence of um like a septic baby there. Um warm and well perfused, the temperature is fine. You always consider maybe the sepsis or a pneumonia in the back of your head. But right now, this is a relatively actually. Ok, baby, just not feeling great. Um and steroids again, not really useful here because it's an issue of mucus and debris build up in the lungs. There's not really a lot of airway edema. So steroids wouldn't really benefit. Um Question mark. Would I give IV fluids in this baby? This one? No. So he's so if I thought he was dehydrated, yes, but he's got three wet nappies. So for his age, that's about right. It's mild dehydration and cap refills kind of on the border. So you can try hear more feeding first. So you clear out his nose, see if he feeds, if he doesn't, you put an energy in and you may consider fluids down the line. But right now, this is not a super super dehydrated baby. So you don't have to jump on the IV fluids. Ok. Does that see any question? Perfect bronculitis is, it's basically a lot of just watching and waiting. There's not really a lot we actually do to treat it. Bronchiolitis. You got 1 to 3 days of Coryza followed by, you're gonna get cough, you're gonna get increased work of breathing and you're going to get sounds in the chest. Usually by definition, they need to have it all free to meet like a nice criteria of bronchiolitis. Sometimes very early on. They may not have some noises in their chest. So we even sometimes call it early bronch. So, um, tug recessions, those are more obvious ones you're gonna get in kids, you get some depending that will kind of hit older bronchitis kids when they're super younger, they might get nasal flaring and head bobbing. But as they get a bit older towards the year, they're not gonna get that sole. Tugs. Recession, subs of recessions will be present in any child who has a work and breathing with bronchiolitis. Ok? And it will usually last about 7 to 10 days. So what we kind of say to parents is it will get worse up until day five and it'll start getting better by day 7 to 10. It could take up to 14. It's usually 7 to 10. The reason it's important to roughly have these numbers in your head is because that will decide your management plan. If you see a kid who's maybe borderline at day two, you know, he's going to probably get worse. So he probably needs to come, he needs to come in. If you got a kid who's maybe just a bit above borderline stay six and it, it got past the worse of the curve. He has got a kind of trend upwards, he can probably send him home. So you, you sort of really know these rough things in your head. Ok. So in terms of managing bronchiolitis, there are three things you need to worry about and that's all you kind of need to worry about. What is their breathing difficulty if they have any, what are their oxygen saturations and what is their intake? So there are some clear, there are clear guides on when kids need to be admitted and there are some criteria on when they are safe to go home and there's a bunch of kids in the middle, but we'll talk about the concrete ones first. So the ones to admit are any one of the apneas, they will know what the definition of an apnea is. Yeah, it is temporary pausing breathing. But how long is an actual apnea? Like what's the time? Cos it blew my mind when I found out 22nd is a bit too high. Someone else, I guess. Or 10. Yes, it's in between. So a lot of kind of English European guidelines say about 20 seconds, some Australian ones say 15. So basically anything longer than 15 to 20 is an apnea, which is an insane amount of time when you think about it. Like, if you actually just count to 15 seconds, that is so long, but neonates and even younger killed kids can just do that up until a year of life. They can just pause breathing for like 10 seconds and it's completely normal. Like that is so long. And I can't imagine as a parent looking at that and be like, yeah, that's fine. But yeah, so an apnea is the fine as more than 15 or more than 20 seconds depending on what definition you use. If they've got severe work of breathing or severe tachypnea. So for example, a lot of like bronchiolitis kids, they'll be at like a respirate of like above 50. And if something like, yeah, fine, it's not above 60 we can leave that oxygen saturations. So this one again useful to know the number because it is in nice guidance. So it's very easy to examine on if they're under six weeks, oxygen, less than 92 they have to come in. That's very clear. Oxygen, less than 90 if they're over six weeks have to come in ve very clear numbers to remember. Um The reason we let it kind of run so low in bronchiolitis is the evidence has shown it doesn't actually have any negative impacts on kids being that hypoxic and they don't tend to actually reattend too much. Um So those are the criteria for kids who can go home. So kids who have to come in and intake anyone who is less than 50%. So bottle fed babies, that's pretty easy. You just do the maths and you get an answer with breastfed. You kind of have to take uh parental um guidance here and the last one is a bit of a soft one. It's wet nappies. So they put six hours apart, cos four, I'd say kind of the first like first three months of life, you're looking for about four wet nappies a day. So in the first three months, if they're taking, you know, 8 to 10 hours between each, every wet nappy, that's the other clinical dehydration as they get a bit older, that number changes. So I'd say the first, the first year, two or three months of life, you want four wet nappies a day if they're around, you know, 10 months to a year, two a day is fine. Somewhere in the middle, you will be OK with three wet nappies a day, but it's not really a hard and fast rule, but definitely neonate four wet nappies a day when you get to about one years old, you can ha you're happy with two, ok. Enter discharge. So if a kid meets all of these criterias at once, they are objectively dischargeable, there's not really a question mild respiratory distress. O2 sats are fine. Their intake is above 75%. These are nice criteria for clear admissions, clear discharges useful to memorize because then it's very easy to apply to your exam questions in the middle. There is a lot of just intuition and what feels right to you. There's not a lot of clear guidance. So like a kid who is kind of borderline, they're feeding maybe around 60 70% their breathings may be moderate, but they're on day seven and they're getting better, maybe they can go home. But that same kid who's on day two might need to come in if the parents are sensible and they live close by, maybe they can go home if they've got 10 Children and both parents are at work, they might need to come in because you can't guarantee that kids are going to be watched at home. If English isn't their first language, maybe you're a refugee living in a hotel, you can't guarantee safety netting as well, maybe you need to come in. So in between these two criteria, there's a lot of gray area and those would be the hard ones. But usually in your exam questions, there will be very clear admits or discharges, there will be very little middle grounds. So in terms of what you can actually do for these kids, so nasal suctioning is an option, but a thing to add is nasal suctioning cos we do a little like Yanker sucker, suck it up can only really is done if you're going to admit a child. The reason being if you need to use this thing that we have in the hospital to help them breathe and help them feed, if you send them home, they will be back in a few hours cos they can't do that at home. So the fact that they need an intervention which you can only provide in the hospital means that they have to come in. You can't just do it and send them home oxygen or op to flow for difficulty in breathing and then for intake. So you, you try your best to do oral feeding. If you can't, you'll do NG feeding and if you can't, you will have to go to IV fluids. Another thing is difflam spray often cause a bronchitis will start as like an so an upper airway throat, red, tender hot, it hurts and then it spreads to the chest dila spray is a nice little local anesthetic. You will see a lot of peds. If you use that on the throat again, you can actually prevent an NG go in cos if the reason they're not feeding is their throat hurt so much. You spray little Dilem and actually their throat is nice and soft and you can feed them orally. You've saved them from an NG tube. And then for the really, really bad ones, you're gonna consider intubation So intubation is your kids? Usually if one with severe apneas or one that you've somehow maxed out on the floor and they're still not breathing properly. Um, antibiotics. If you think they're septic and IV fluids, if you've done all of the intake stuff and it's not helped and they still are dehydrated or just out the box, they come out really sha they cap refills, like over three seconds, their heart rate is really high. They're cold. Their motto. Just go straight to IV fluids. OK. So uh before we go into the kind of wheeze asthma stuff, any questions so far? Cool. No questions. I'll move on. So Bronch Pharyngeus, wheeze and asthma all kind of on a continuum because they're all kind of similar diseases. So these are rough kind of age groups you use for each one, but they're a bit softer on the edges. So bronchiolitis, it used to be anyone under one year's bronchiolitis. Anyone over a year is a viral induced. Wheeze, especially post COVID. It's getting a bit more messy. We're seeing bronch up until about two years now and viral induced. Wheeze, you can get maybe a bit for one year. So sometimes what will happen is if they're at like 10 months or 11 months, you've got some weird, not obvious crackles, people can try for inhalers. If it doesn't work, it doesn't work, then you have your answer. But generally we say up to a year for bronchiolitis over a year, it's mostly can be wheeze and say when we get to the other end of the borders is five years. So we say five or above for asthma, the reason being you have to be able to do the spirometry and all the like intensive tests to be able to diagnose it realistically, no one actually does though. So it's an arbitrary cut off but it's one people use. But also another probably more important thing is a lot of kids will have like lots of b squeeze episodes as a kid and then grow up and do not have asthma. So we kind of delay locking them into a diagnosis unless we have to in saying that there are some kids where they'll be under five, they maybe like three or four, they have like four or five ed attendances a year with wheeze and a lot of interval symptoms in between. So with those kids, well, not definitively, asthma, we will treat them as asthmatics. We will put them on low dose corticosteroid inhalers. We will treat them as if they are asthma. So effectively they are, but they won't get the diagnosis until they hit year five. Ok. So going through the differences. So bronchiolitis again, age to under one most likely bronchiolitis, they can go up to about two years old. Crackles, crackles and bronchitis is a very kind of unique. It's basically everywhere you listen and there will be crackles everywhere cos all the mucus in these little airways and then they'll cough and all the crackles will be in different places. They're just saying that if you want to diagnose bronchiolitis, send free med students at one patient, it will all come back with a different answer. That is bronchiolitis cos that's how much your chest are constantly changing about where you hear the crackles rather induce. Wheeze again, you're looking at your age. So typically you're over ones up to about fives in the history. You're looking for a few days, cough Riza preceding it and it's only one trim, it's only viruses. So don't have a cold beforehand versus like an asthma where it can be triggered by other things. So if you go to asthma again, age, you're looking five or above. But as you said, it could be a bit early, but looking five or above history is some people may only get um one viral trigger, but some people might get other triggers. So they might get it after working out, they might get around uh summer with like hay fever saying it often they might get around pets. So you're looking for a more broad history. Some people only have viral induced asthma, but you, you typically get a broader kind of history ATP in the family is super, super, super predictive. So if you've got a parent, if you've got a family, when we say HP family, we mean immediate family. So parents, siblings that we don't really care about aunts and grandmas and all that stuff. If parents and siblings have a conditions or they all, they have allergies, they have um, asthma, they have hay fever, they have eczema. This kid is more likely to have asthma as well and a big one is regular symptoms. So if they're getting interval symptoms, that kind of almost gives you an answer cos when you squeeze, you're definitely not getting into the symptoms. Um, and then morning and night, so often the kids will get first thing in the morning and last thing at night, they, their asthma will play up a little bit and they'll need their inhalers. And then when we're looking at the kind of five in older kids, sometimes to differentiate asthma and infective asthma or pneumonia, not always super easy, but generally in asthma, you shouldn't hear crackles. If you've got a kid over five, he's got some wheeze and he's got some crackles. You get what's called infective asthma. So it's, um, disc infection has set off whatever their asthma is. Um, or they have a pneumonia. And the thing is if you have a pneumonia that can also, you might get a little bit of a, uh, scattered wheeze. But differently, you kind of get crackles in the area. So if you get like localized crackles, even if they're asthmatic, you're thinking pneumonia, high fevers, you don't typically get high fevers in asthma. But again, it's not super specific. But typically if you're seeing high fevers, you're thinking maybe this is an infected picture rather than just asthma. And then of course, if they're septic and they've got wheeze or they've got your breathing, but if they're septic, you treat, there's a bacterial infection, they may or thought we have an asthma attack, but you treat the sepsis. And then this one, I just leave it on screen for a sec. This is from nicest page about differentiating the things not gonna go through it because we just talked about it, but I'll leave it on the screen for about 10 seconds in case anyone wants to screenshot it or anything. So we'll go to V induced wheeze and asthma and together is you effectively assess them the same in terms of like how you rank severity and then you also manage them the same. So if you look so you have moderate severe and life threatening. More modern guidelines don't really acknowledge that moderate asthma exists. So they didn't even give it criteria, but this is coming from BT S from a few years ago. So if the O2 SATS are above 92 they complete sentences in one brain after they got Myot myot apnea, we say moderate asthma. And in the Ed, you will see a lot of people still using the word moderate because it's, it's useful. It may help you conceptualize it. So that's moderate asthma. Um Then you have your severe asthma. So with the severe asthma, basically, the way to centralize it is someone speeding up. So their O2 SAT will be low. They can't complete four sentences because they're breathing so fast. They're getting severe tachycardia, severe tachypnea. And when it's really bad and scary, it's almost also a little bit reassuring because the opposite is life threatening asthma. C So with life threatening asthma, your fingers, someone slowing down. So you've had that phase where they're getting really severe, they're getting really fast and then they start getting confused, their chest gets silent, the BP starts dropping, they get exhausted. Um, but these are like your life threatening. Like you don't really get BP changes in asthma but you kind of at your life threatening point, you might, but generally if you see a kid really, really chill, really not reactive with lower O2 sats that needs to make you worry cos if they're having low O2 sats, their natural body response should be to speed up and the fact that they're not should be worrying you so don't be like, oh, if sats are 90 but he looks comfortable, that should worry a little bit. He should be uncomfortable. Uh Another thing that also makes it a bit harder, especially if you want to do PED nighttimes and evenings because is this kid quiet and chill and subdued because they wanna go to bed or are they exhausting their chest out? So, here again is just a screen that if you wanna take a picture of do it. But it just kind of says what I said before but more numbers in it. Oh and also I think if they're above five, U usually above six, but if they're of the age of asthma do a peak flow, it's super super useful such an objective metric. That's one of the few objective metrics we have. So it's great use it if you can really, really important to do uh peak flows. But generally you kind of need to be about 56 to have the skill to be able to do it. There was another school which exists which got used in one of my first places I worked in peds, not ever seen it since. So it's kind of left over in the presentation, but there's something called a pram score. So it's like a pediatric respiratory assessment measurement score. Um So it's basically different works of breathing different obs you put it into a thing and it gives you a number to quantify how of areas given that BT S has clear guidance on theirs. I don't really use it anymore, but everyone needs to use it in my own trust. So I should leave it there if you wanna know about it. So, first line for asthma, what is the management? So there are three things you will give in asthma every time it stop some of them. But in asthma, you'll get it every time it stops is one or two more. It's steroids. Yeah, one more. Actually, technically, you might not always have to give it, but you will consider it. There is another thing you always consider in the first line. Yeah, perfect. So good job bars. So, I atropine, we'll get onto that in a sec. But, so oxygen, we talked about it acutely, I say a 9498 but often we're happy with 92 but theoretically 9498 is the best. But if they're 9293 like we'll accept it. We're not gonna give you, we generally don't give you oxygen. If you're 9293 we'll accept that. Um, but if they are deserting, we kind of aim to bring them back to 9498 and then we'll bring them back down. But that's why it's got a weight in it. Birth therapy. So what birth means is one puff. I said every uh 30 to 60 seconds. That is actually wrong. I don't know why I put that. It's one puff. You say your parents have 10 seconds or five breaths. We, we say that because often kids are fine, you can't count your breath. So we 10 seconds and then we'll do the next 11 cycle will have 10 puffs in it. So it should, might take around 2 to 3 minutes and then we will do, oh, this is Yeah, also out date. Um, we do free cycles. So you do it at zero minutes, you do it at 20 minutes, you do it at 40 minutes and at 60 minutes you assess them. So in a burst, you are getting free cycles. The 60 minute is the assessment. So you've given free rounds, you've given 20 minutes, cos you wanna give time for Salbutol to work and you have a list to see if you've made a change. And then you can include tropium here, but we'll get onto it cos it's they usually be a bit more severe and the last thing is steroids. So, steroids, oral pred IV hydro, all the evidence shows they are equally effective. So if your kid can take oral, give them oral hydro IV hydro isn't stronger. So don't just necessarily give it because they see more and more like if they can take oral, just give them the orals and anyone coming in with asthma will have free nasal steroids. That is clear BT S guidance that happened if you have to come to the hospital needing it, do free days of steroids. There are rare situations where you won't, but as far as you're aware for your exams, free day, the steroids, if they're, you use atropine bromide, they have them as inhalers and they have it as a nebulizer. When you look at BT S guidance, it mentions nebulised Atrovent. It doesn't at all mention ipratropium slash Atrovent is the brand name for a drug. It doesn't actually mention it as an inhaler. So if you're following BT S guidance, if they're not needing oxygen, and therefore by definition, not needing nebulizers don't give Atrovent. It's not under guidelines. Some people still do cos it makes us feel like we're doing something, but that is what a guidance says. Nebulize Atrovent. You do that. If you're doing nebulized albut and nebulize Mao if they're really severe, it's something you can consider. But again, I don't think I've really seen it, but it's something that exists. If you go into your second line you're doing. Uh I think somebody tumbled in like I might, I need to get uh I don't cool. Um uh There you are. So your IV drugs. So the one we know where it goes clearly is IV. Magal. That is always the first IV drug you go to. You've done IV, you've done all your inhaled stuff and it's not enough or straight out the bat. They look so so bad and you're like, I'm gonna do all the inhaled stuff, but I need to get IV as well. They're just looking so, so horrible. They're des acting so hard. They water even so bad. Then there is IVC tomorrow IV Theophylline. There's no explicit rule about which of the want to go first and it's changing now, from what I've seen now, almost everywhere I've worked, I think everywhere I've worked. IV, Theophylline. Is your second line. IV, salbutamol is your third line. We don't really use IBS IBS M that often anymore. The idea being if they're having birth, the salbutamol receptors are going to be so, so loaded that any F IV isn't actually going to work under adrenergic receptors in a youthful way. You want it or you're just gonna get the side effects, you're gonna get the lactic atos you're gonna get feeling awful but you're not gonna get the clinical benefit. So IV mag myself softly, we say IV theophyline IV bu that's diola. So number three, actually, before we go into SBA free, any questions about just wheeze or asthma? Cool. No questions. Um The only thing that actually one caveat I want to add as well is if you viral induced wheeze. So we say below five, it's often also called preschool wheeze. If viral induced wheezes, most places won't give three days of steroids anymore. Some older djs have worked out have done it but all the kind of more modern up to date London Teaching Hospital, we also don't do steroids for around do wheezes or some places do. So there's not actually, it can't give you a correct definitive answer there. I will are on the side of if we don't give steroids for mild wheezes, which can go home a wheeze which has to come in will often give steroids. But if it's a mild wheeze, which is the vast majority that we might give some burst or one will give some burst. They'll recover. Well, they'll go home. We don't give them steroids. But I'm sorry, I can't give you like a definitive answer on that one. So, number three, I should give you a few seconds to read it and then just answer three. Cool. Yeah. Well, so you got it right. So, it's a DK, a confusion if you're often preceded by some sort of illness or a viral gastroenteritis or a viral, they reduce skin to. So they're dehydrated. The abdomen is tender but not guarding. It's a very important thing with abdominal pain in slightly older Children. Think about DK A. It's a very easy way to miss it. You just see, oh, some sort of vomiting, they're a bit dehydrated. Their abdomen is tender. You just think of viral gastroenteritis. We should always be considering a DK A. Um And that's why often A B BBg is just so useful in those situations. You don't do it in every single gastroenteritis. But if you are considering it getting a BMG is super useful and a urine dip again, super useful because not only does it tell you ketones, it can also tell you how high sugars seven go through DK. So I'll try, I'll go through it a bit slowly. But if at any point you have questions, please do. The DK is so, so complicated to wrap your head around or at least I found it really complicated. So if you want me to slow down or repeat a point or clarify, just ask me. So the things you actually need for the criteria diagnosis according to the British Society of Pediatric European Endocrinology and diabetes is presence of ketones and presence of acidosis. So, ketones, we say free millim all the more acidosis, we say ph less than 7.3 you will almost every single time get um high sugars as well. Cos actually not necessarily for diagnosis of DK. So that's why it's not under criteria, but almost every single time you'll get a hyperglycemic child as well. The guy talk about being aware of you glycemic DK. I don't think I've ever seen it. Everyone I talk to has never seen it as well, but typical sensation, high sugar, high ketones acidotic. So you're going to break down a bit more is there's DK grading. So this one useful worth taking a picture of as well because you do need to know these for your exam. It's a very easy one to know the numbers. So it's one that you have to know the numbers because the way you grade DK severity is the PH levels and the PH levels will also define your fluid management. So you need to be able to tell that when you're looking at a question, they'll give you a phd. What does that mean? So take a picture really useful to know. So DK at the front door, you figured out it's DK. You think it's DK A? What are you gonna do? So you, you, if you do your ph, you do your BMS, do your capillary ketone and the glucose, you do urine dip, look for ketone, they look for infections and your blood. So you get a formal glucose, you get urine and electrolytes because potassium and so are gonna become real important real quick. And also it will help you assess the dehydration C RP. How bad is their infection? F PC? Do they have an infection? So those are what they are looking at. Often these get done at the same time, cos DK is often the first diagnosis of uh diabetes in Children. So if this is the unknown kid, so a kid who's not got known diabetes and N DK A, he also had an HP A1C T FT S. Celiac co autoimmune stuff often also happens in diabetic kids cos of all autoimmune stuff, but the ones in blue aren't life threatening. But if you do it later, that's fine. It's not at all a problem. So you're gonna have to do fluid bonuses. So for anyone who is not shocked and by shocked, I mean, just the clinical signs of shock which is reduced skin t um cap refill mucous membrane stuff like that. Heart rate. Yes, a little bit and BP, yes, a little bit. But kids are really resilient kids. You've got to lose about 60% of your internal circulating volume. It's like 40%. So 40% to 60%. Either you've got to lose nearly half or just over half of your circulating volume before you show tachycardia. So it's not the most useful neces and dehydration in kids. Um So if they're not shocked, every kid gets a fluid bonus in DK A. So if their ph is 7.29 they clinically don't look shocked. You still get no bonus. A look shop. So uh over two week tech card BPA combination of all these things, um we give them a bolus but over a shorter amount of time here, they say cap refill over two for their definition of shock in real life. You can, you go up to free, you got up to free, that's fine. But there is a bit more conservative definition here for the DK kids. So you do it. If you're not getting the response you want, you can do it again up to four times. After four times, they'll be going to pick you. You consider iron trumps, but it's useful to know you can do it up to four times. So after you've done your boluses and I have you done a bolus in a non shop child? So you're just fulfilling what you have to do or you're doing it in a shop child and you've got to stable, that's when you move on. So once your child is stable and they've had whatever amount of bonuses they need, then you look at rehydration. So if there's severe decay, the patient is less than 7.1 you, you 100 mil per kig. If the ph is over 7.1 you do 50 mil per kig because the PH is actually the better indica indication of mild or moderate dehydration. There are older things you might have heard about 5% dehydration, 7% dehydration, 10% dehydration. Don't worry about that. It's not really used anymore. You just look at a ph that will tell you how much rehydration fluid they need. If they are not shocked Children, the bonuses you give, you remove from this rehydration amount. If they are shocked, any bonuses you give, you don't remove from the rehydration amount, then you're looking at maintenance. Maintenance is the same for all the kids regardless of shock or on shot 100 mil for the 1st 10 kg, 50 mil for the next 10 kg 20 mil. For anything more classic pediatric numbers need to know for fluid. Again, a super easy exam question about even in non da cases like how do you rehydrate a child? Just wait for your question to finish right. So over the next 48 hours after you've done your initial boluses, you've calculated what rehydration fluid they need and you've calculated the maintenance amount of fluid they're gonna need for 48 hours. Combine those two numbers then divide it by 48. It's a bit complicated, but we'll work for an example together. OK. So um fluid choice. So bonuses is just always flat sodium chloride. That's the answer. Don't worry about anything. That's just flat sodium chloride. When you're looking at rehydration slash maintenance, you're doing sodium chloride plus potassium. The only caveat was when little star is there is if they're hyperkalemic. So if they're over potassium, go for 5.5 you need to make sure they're peeing that they're not anuric. So that way they can pee out if you give them too much potassium. And um you want the potassium to come back to normal before you start giving them more potassium. But if they're not hypokalemic, they give fluid, you need to give them potassium because all the insulin you're giving is gonna make them hypo hypokalemic. The other one here of sodium chloride plus potassium plus glucose you will use if their glucose eventually drops below. I think it's 14 or 11. That one, I don't know off the top of my head, but there's a number with the glucose. If it drops below that, you'll still giving the glucose. But until that point, it's just sodium chloride and potassium, that's your fluids. Insulin infusions, you do 0.05 to 0.1 units per k per hour only after you've done fluids for an hour or two. I've heard the explanation for why I can't remember why but yeah, reason is something. Uh But yeah, in a lot of places, they just default to 0.05 for the units per K per hour, only 0.1 if they're more sever. But that's the kind of range you're looking at. And usually in your questions, there will be clearly one of those two options. They're not going to give you two and you got different, but 0.05 to 0.1. That is the amount of medicine you have to give regular observations. So you do fluid balance chart, you're gonna be doing hourly to two hourly to four hourly, glucose, keto and PG un neuro os normal nobs just know you have to do them. You don't have to memorize how often because it's really, really, really complicated, fine and then to define DK resolved when the child is clinically well, tolerating oral fluids and ketones less than one and ph normal. You need all four of those things and then you say DK A resolved. Ok. So before I go to the worked example, anyone have any questions? No, cool. We'll keep going. So a 14 year old cat refills free weak pulse, heart rate, 95 BP kind of borderline 50 kg ph of 7.05. What severity of DKA is this child looking out with ph what's the severity here? Yeah. Perfect less than 7.1. So we say it's severe. Perfect, good job Raja and Basha. So clinically, your child is also shocked. So we're gonna use that for the first part of calculation. We're gonna give 10 mil 1050 K. So we're gonna have 500 mil over 10 to 15 minutes. So this one, we're gonna assume that one was enough. The cap refill is now less than two. Their pulse has come back stronger. We only need to give one bonus in this example, rehydration because their ph is less than 7.1. So we say severe DK 100 mils per kid. So it's 5 L, the maintenance 2100 mil for 24 hours, 4200 mil for 48 hours. Therefore, after we've done that 500 mil bonus, we are going to add together their rehydration amount and their maintenance amount and to get a big number 9200 then we will divide it by 48 and that's our hourly rate. So this kid will be in hospital for a minimum 48 hours. Usually any questions on that look good. So just note if the, if the skin wasn't shocked, we do the first bolus over 30 minutes, you can go a bit slower if this kid's ph wasn't less than 7.1. I would have given him 50 mil per cake rehydration. And if this kid wasn't shocked that bolus that 500 mil I would have taken away from a total of 9200 before dividing it by 48. Ok. And just wait from the G A question. Ok. No worries. So that's all the teaching done. The last few slides are just questions. So at least just one or two people answer, please and then move on to the next one. We'll get it all out of here in about 5, 10 minutes. Ok. So I'll let you read it and then be able to take a shot. Cool James via and Raj, you're all right. She an asthma not responding to treatment. They're also quite psychotic and high lactic and I put that there because the other option IV Salbutamol make their heart rate and the lactate even worse. And we know by this point they'll probably also have you m up anything more that would do anything that's just gonna make those complications that are already worse, intubation. Where would intubation be an option? So, for this kid, if he was so silent or so exhausted that he was unable to maintain a reasonable breathing rate himself, that would be one of them, but we might bag that mask first. But that's the reason what we consider. Uh or if he just went into respiratory arrest, if not one as well, there are very rare cases where there's work and breathing. So, so, so high you might consider it, but usually there will be horribly work of breathing for so long that they'll get exhausted and then we'd intimate that would be the situation when you go for intubation. Does that make sense? Perfect. Yeah, intubation basically is only really considered at a point that they can't breathe for themselves. One. Mhm. So, well, you got it right. So I think everyone who picked e you're right in the sense of you get the most for 15 minutes, you correctly identified this child was in shock, reduced skin turgor, low BP and low heart rate. The only mistake you made is when you're doing your initial bolus it is pure sodium chloride. That is a fluid choice. Give potassium that fast. Oh God, that would be horrible. That would be life threatening to the heart for your rehydration and your maintenance fluids. Then you add in the potassium. OK? And for other options, insulin, we don't do until that 1st 1 to 2 hours afterwards. Glucose. We don't do until their BM has dropped and it's below 14 or 11. I can't remember the number. Um D is also wrong because that is the B for a non shocked child. Does that make sense? Do you not need an ABG for the potassium ABG? No. Do you just need a blood gas? So VBG will tell you that the potassium is like too high or too low. An ABG you only really need if you need a CO2 in someone. So that's why we rarely, rarely haven't do it in kids. Perfect. Oh I just get uh had go this one? Cool. So, Raj and Gia, you are correct. This child can be safe netted. Uh ras if you don't like if you don't have to. But why would you wanna admit this child? I just wanna see what went through your head. What made you worried about this? I think. Sorry, there's a vacuum in the background. Um I was thinking kind of about the fact that it had been five days. I know it's not like she still could be in the middle of if it's a bronchiolitis. But I think I was kind of on the fence about that and then her oxygen saturations as well. I wasn't too sure. Yeah. No, and that's all reasonable. Yeah. So you're right. Day five is not a definitive number, but that's why trends are more useful in this one. We don't exactly give a trend but you day five just ask, are they getting better? Are they getting worse? And sometimes you get an answer of, yeah, they are getting better. Parents have just come because of how long it's been. Um And then, yeah. O2 likes it because they're um because they, because they're six months we're happy with 92 or above. Does that make sense? Yeah. Thank you. Good. But yeah, so it's a baby who's babbling. So they're interacting well with you. Mild subcostal recessions, mild intercostal recession, feeding is 65%. So it's in that gray area and they're five wet nappies. So they're not dehydrated and clinically. Um, they're not, I'm sure no sign of dehydration in the story as well. So, because they're well hydrated, they're at day five, they're probably at the worst point they're gonna be, they're not too bad. They're probably safe to go home after child's day one. I'd reconsider this answer. Um, so for OG cutoffs it's 90 or above if they're less than six weeks, sorry. 92 or above, if they're less than six weeks, 90 or above, if they're more than six weeks. So second, they go to more than six weeks, we say 90 or above for bronchiolitis. For asthma, we say 92 or above for bronchiolitis, 90 or above if they're above six weeks. Does that make sense? Cool. So number seven cool. So the answer is E so matriptase, we say 01 to 1 to 4 and then later at baseline, we will often never get zero hours because that would mean you have to be there when the symptoms happen, which is gonna happen. So we say zero, which means just do it as soon as they arrive and do one a few hours later because more importantly, it will give you a trend. So uh that's good. Any questions about this one A is just the wrong dose. B right dose, wrong route C, right dose, long time for the Masto tryptase and the wrong dose and hydrochlor and chlorphenamine aren't part of the acute management anymore. So take messages, most emergencies, nice or BT S or someone will have like defined criteria. It just super, super useful to learn them because for exams they often follow it. And then for any oy while there's a lot of nuance impedes. If you fall back on the guideline, no one can say you're wrong, like no one because you're following a guideline, you are fine. Um for acute conditions, a lot of them have admission criteria. So if they have them learn them and then finally with all acute stuff, kind of all medicine in general, try and split your management options into categories and just kind of help it easier to conceptualize what you're trying to think of like what you're actually trying to treat and then what are your options to do that? Ok. So you're all gonna do really, really great. You're gonna smash your exams. You're gonna have a great time. You have a great summer when the summer comes. Ok? So I'm gonna leave my feedback for here. Please do. It takes less than a minute, means a lot for my portfolio. It's really important. And in the meantime, if anyone has any questions, drop them in a check, you can unmute your mic. I don't really care. So any questions if you have them, I'll be around for a few minutes. But if you don't have any questions, I will hop off. Thank you. You all right. And Russia has dropped the link in the chat as well for the feedback. No worries. Thank you guys for coming and I will hop off. I.