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Final Year Series: Paediatrics- Paediatric Emergencies

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Summary

This interactive teaching session focuses on paediatric emergencies that are integral to the UK MLA finals. The presenter covers several key conditions such as anaphylaxis, meningitis, sepsis and reviews asthma and arthritis from the last session. The session allows learners to develop a deep understanding of the emergency management of symptoms related to these diseases. The presenter takes a comprehensive approach to explain each condition using relevant case studies. Participants are encouraged to interact and apply their learning through polls, instant chat, and Q&A, making this a highly engaging session. The session also provides important exam tips and the presenter encourages follow-up questions via email, offering ongoing support for continued learning. If you're preparing for the UK MLA finals or looking to update your knowledge on paediatric emergencies, this session is not to be missed.

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Description

Presented by Dr Chrissie Allan this session will cover the key topics surrounding paediatric emergencies to help you to prepare for the UKMLA.

Learning objectives

  1. By the end of the session, participants should be able to identify the main pediatric emergencies for the UK MLA finals, including anaphylaxis, DK A epic arthritis, meningitis, and sepsis.
  2. Learners should develop a thorough understanding of the importance of observing patterns, and not just raw numbers, when assessing a sick child's set of observations.
  3. Participants will gain knowledge on how to assess a child's work of breathing and understand the significance of the APL S guidance on efficacy and effect.
  4. By the end of this session, participants should be able to recognize and diagnose the symptoms of different pediatric emergencies based on case studies and SBA questions.
  5. Participants should also be able to understand the presentation of bacterial meningitis, how to diagnose it, and know how to ask appropriate history questions for pediatric patients.
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Computer generated transcript

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

Hello. Um We'll get started in a minute and if someone in the track just let me know if you can hear me, OK? Is everyone able to hear? Ok, if someone can just put a message in? So I know perfect. Um We'll get started because there's quite a lot to cover in this next hour. So thank you for joining this evening. We're gonna be going over some of the pediatric emergencies that are important for your UK MLA finals. Um We won't be able to cover absolutely everything, but at the end of this slideshow is my email address. So if you have any more questions, you can email me and I'll try and answer the best I can or point you in the direction of someone that can answer better. So, um some of the key UK MLA conditions you can see sort of on your screen now. So acute asthma recovered in the last session in December. So I'd go back and watch the respiratory video if you want some revision on that. Um We're gonna look at anaphylaxis DK A epic arthritis is also an important one that we covered last session as well. Um meningitis and sepsis. So we're thinking about emergencies. We really need to think about the sick child and sort of an important point. This is both for adults and pediatrics is to remember when you're looking at a set of observations, it's not just the raw numbers that you want to be sort of caring about. It's the pattern of them as well. Um for example, it's the heart rate rising. Is it reducing? Is it staying around the same? Is the respiratory rate high? But it's been staying consistently high. Um Is it now getting lower? Are there signs that this child is maybe tiring um and not able to compensate as well or is it in increasing? Is that sort of respiratory distress increasing even more? Um We also want to look at an assessment of the work of breathing again. This was covered in more detail last session. So just a bit of quick revision, some of those things that we are looking for are listed there. So the nasal flaring, um any tracheal tug, the subcostal recession. So that's the idea of the skin being sucked in below the rib cage, the intercostal recession. So that's between the ribs. You might see the skin being sucked in there and suprasternal. So that's above the clavicle is the skin being pulled in. Um And remember the APL S guidance of this idea of e efficacy and effect. Um So you're always asking yourself is the increased work of breathing that the child is doing is that effective or ineffective? Because there is a difference. You might have a child whose respiratory rate is high but their oxygen saturations are ok. Uh They're showing some of those increased work of breathing signs, but they're coping quite well with it. Same. We're gonna start with an SBA question. So I'll read it out once. Um I'll then give you a couple of minutes or a minute or so to have a think. And I'll put a pole up where you can put your answers. So, question one, we have a three year old child brought to the emergency department with a two day history of fever, difficulty swallowing and drooling on examination. The child is sitting upright, leaning forward and appears distressed. The throat is red with slight swelling of the uvula, but there's no exudate. The child's temperature is 38.6 and heart rate 100 and 30 on auscultation. The lungs are clear and there is no neck rigidity. Which of the following is the most likely diagnosis. I'll give you a couple of minutes a few seconds and then I'll put the pole up for the. So hopefully you can see that pole now. So give yourself a minute to read through when you think, you know an answer. Pop it in. Perfect. That's great. Hopefully you all kind of got that and that wasn't following each other. If anyone's brave enough to kind of put in the chat some things that have pointed you towards that as an answer over one of the others or how you excluded something. If you do that now, just a couple of words and then we'll go through it to make sure everyone's on this. Anyone wants to give it a go. Yeah. Perfect drooling and tripod positioning. They are really your, your key indicators that this is tis that we're looking at. Perfect, moving on. So about the same thing, the leaning forward, that's the tripod position. The difficulty swallowing the drooling is really the key one. So that's sort of pointing us towards erotis over the others. Just a little bit of an explanation. I don't think we need much of this cause everyone who got it right. Um But you've got your classic signs of dysphasia drooling the respiratory distress with an upright or a tripod position. Um in the absence of ate, that's kind of pointing to away from acute tonsillitis or a peritonsillar abscess. However, I do want to point out that although the questions then include some examination findings, you really should not examine a child who you think has epiploitis as it can cause more distress and it can cause that airway to narrow. Again, we covered this last session so you can go back, want more information and here's just a bit of a summary table that you can take from the slides when we're finished or you can screenshot. Now. Um just of those differentials, obviously, there's many other respiratory differentials that could be included, but just looking at some of those key symptoms, what you might find on the examination and the differentiating features. Um these will be useful for your Aussies where you may be speaking to the parent of a child, but also in your SBA questions cause sometimes um it's a about picking out those keywords to help you get the diagnosis, which can at times be a little bit tricky. So we'll move on to our first sort of pediatric emergency condition presentation that we're gonna cover tonight. Um And we're looking at bacterial meningitis. So some of the key things that you just need to learn and be aware of. So the most common causative organism is the Neisseria meningitis and strep pneumonia in neonates. Be aware of group B strep as that is the most common causative organism. Um My question for you again, just one or two word answers, whatever you can offer. How does meningitis present if you pop some answers in the? Yeah, great. We have fever. Anything else? Any other ideas? Headache, all the ABN, blunt and rash, headache, neck stiffness, nausea, perfect. All of these are great answers. So we have that red flag combination. Um the fever headache, neck stiffness, photophobia, altered consciousness or cognition that you sort of commonly read about and also can be quite a common sort of flag within exam questions. Um, we will break down the presentations a bit further because in Children, everything can be that little bit more difficult to identify. Um, neonates in particular can have some very nonspecific signs and symptoms. Um, you might just, they might literally be, my baby is not feeding very well. They're more, they seem more tired. Um, and it's kind of making sure that you remain with a higher sort of suspicion that meningitis or sepsis could be what's wrong with that baby. Um And just a little ay tip that I'm sure a lot of you are aware of, but just in case to add to some extra points in your ay stations, when you're taking any form of pediatric history, always ask about feeding and changes in the feeding that the parent or carer may have noticed as well as wet nappies and changes in toileting habits. This goes alongside sort of the ba bit of the birth history. Have they had their vaccinations, et cetera, et cetera. So to break down the appearance. So here's some of the breakdown, the presentation, sorry, here's some things that you might notice on appearance. This is on your examination, you have the bulging Ponton fever. Um It's actually less common in babies, but um it may still present that way. Also ask about anything that may have masked a fever. Have they already given the child calpol at home trying to bring the fever down? Um Do they have a generally ill appearance. Did they to you as a clinician look ill? Um as well as to the parent or carer that, that knows the child very well. Do they look ill? Are they pale mottled or cyanosed at all? Um And the non blanching rash is very important to be aware of. It's mainly a meningococcal disease, but we almost want to deemphasize that a little bit because it's generally a very late sign and it has become less relevant now in sort of the post vaccine world. Um, but if you are seeing that you would definitely be very worried a bit about behavior. Essentially. Any change in behavior with a child could be a sign that they're very unwell. Are they more sort of irritable than normal? More lethargic that reduce feeding any sort of unusual behavior is a child that's normally quite calm, suddenly a bit more aggressive or agitated by things like, um, are they more subdued? And normally they're a bit more sort of energetic and you can tell that even with a baby and if normally they're wiggling around a lot and now they're just quite calm. That might be unusual. Do they have a cry of an ill baby? So a weak sort of high pitch or a continuous cry that is not normal for the child? Again, this is where it becomes important that you're looking at the patient in front of you. But also speaking with that parent or carer as to what they've noticed any changes and they'll be able to guide you with that. So, neurological signs that you might see is Oto consciousness or cognition, the focal neurological deficits may be present, headache, um may be present again, you have to use a bit of detective skills if the child's unable to tell you if they've got a headache. Are there signs that they might have a headache? Um, neck stiffness, this includes slight discomfort or reluctance in moving the head. Again, this can be very difficult, especially the younger the child. Um, but if you go to move them or the parent or carer goes to move them, are they very reluctant to do that? Normally a baby, um will start to turn it once it's able to move its head, will start to turn its head towards a parent or carer saying its name or cooing at them. If they're reluctant to do that, that could be a sign that they've got neck stiffness, photophobia and obviously on the extreme end, you may see seizures as well and then other sort of presentations, tachypnea, um, grunting apnea. These are all nonspecific signs of illness, but it does include sepsis and meningitis and having spoken to a consultant who checked over these slides that works in pediatric A&E. These are actually some of the most common presentations he sees in Children that then turn out to have meningitis or sepsis as well. Um, unexplained body pains. This could be anything, limbs back abdo um or vomiting. So I think we've had um a mention before. But does anyone know of any special tests for meningism that you may be required to perform in acies or that you may have read about? Yeah, so we have kings and brisky signs. Um So there's some diagrams there that hopefully um illustrate it quite well, probably practice with any housemates or family members you have in case you do have to show these. Um But essentially B Brodsky's is the one where um the hips will flex and knees will flex in response to you flex in their neck upwards. And Koenig's is the one the resistance to extension of the leg while the hip is flex. So just kind of get your head around the difference between those when it comes to making a diagnosis. This is based on guidance. Um A senior should always make an initial assessment with a suspected meningitis case and ensure that antibiotics are started within an hour of arriving at the hospital. Um Blood tests and lumbar puncture should ideally, well, they should always be completed before starting antibiotics. Um But that's only if it's safe to do so. Um Normally you'd confirm a diagnosis of bacterial meningitis based on those clinical features and blood test results and the lumbar puncture results, but don't delay any treatment to a child in trying to ascertain a full history. So that leaves us nicely onto the investigations. Um, so I've listed them there, some of the things you may want to do. Um, lumbar puncture, I've kind of alluded to this before, but you need to make sure you've treated and stabilized the patient before performing a lumbar puncture. Um, so it is recommended for a lot of Children, but we don't want to delay treatment. Think about your A two E what is the biggest risk for life? Um and make sure that that patient is stable first before you move on to lumbar puncture. Ok. Lumbar puncture interpretation. This is something that's very much um possible to come up in sort of an SBA question or an exam question. Again, this is a slide that I'd probably screenshot or take off of the slides later on. Um Just so you can go over that before exams and just some of the differences that you might see between a bacterial and a viral sample. Now on to management. So if you are in a GP setting and you have a child come in and they are unwell with a non blanching rash, make sure you give them antibiotics straight away and transfer them to hospital. So that is an unwell child. They need antibiotics. Um In the hospital, things are a little bit different because ideally you'll be able to do those blood cultures and a lumbar puncture first. But if the patient is very acutely unwell, then again, antibiotics should not be delayed. Um, and you should keep a low threshold for treating any suspected bacterial meningitis. Antibiotics can always be stopped if it turns out that that's not the diagnosis and something else needs to help, but you should keep a low threshold and not delay treatment at all. Um, you always need to follow your local guidelines regarding the choice of antibiotics because that's based on resistances that are in the local area. But in general sort of for exam purposes under a month, you might see some places that say under three months, um cefotaxim and then plus amoxicillin and that amoxicillin covers for listeria um above 1 to 3 months depending on where you are. Um cefTRIAXone in some places. This is being given to any over two weeks, which includes the hospital that I work out. They'll use cefTRIAXone in any babies that are two weeks or older. So it's always worth being aware of local guidance when it comes to working. But for exams, you can remember it as is on the slides. Um you're kind of step up. So um Vancomycin is kind of one of these very broad spectrum antibiotics that we would add if there is a risk that um there might be penicillin resistant pneumococcal infection. Remember to ask about recent foreign travel, even for young Children. Um steroids have a good role and that's used to sort of help reduce the frequency of some of these complications that we hear about. Um and that would be dexamethasone usually um four times daily for four days to Children over three months if they're found to have bacterial meningitis. And then another kind of UK MLA note. Um part of the curriculum is that, you know about notifiable diseases, both bacterial meningitis and meningococcal disease are notifiable. So public health will need to be informed as well. Ok, viral meningitis. Um The causes to know about this are the herpes simplex virus, the HSV enterovirus and varicella zoster. So VZ V, um A sample should be sent for viral PCR testing. So um when you do that lumbar puncture, you send some for viral PCR testing. Um kind of a viral meningitis tends to be milder but don't fall into that trap. Um because HSV meningitis can be absolutely devastating if there's any kind of history of HSV cold sores, anything of those such. Then um and you're suspecting or screening for sepsis or meningitis, then give acyclovir as urgently as you would give antibiotics in a suspected bacterial meningitis. So, the complications, this is kind of the last thing to be aware of for meningitis. Um So, hearing loss is kind of a key one. seizures and epilepsy, cognitive impairment and learning disability, memory loss, cerebral palsy with focal neurological deficits such as limb weakness or spasticity. Um Luckily, we are seeing less of this, but it does still happen. I've recently treated an adult patient. Um an adult male who is 38 years old. So he's done very well, but he had meningitis at 10 days of age and he has cerebral palsy, severe learning difficulties. He's paraplegic and relies full time on his um mum as a carer. So this can be absolutely devastating illness. So it is important that we're catching it early. Ok. So our second question of the night, um we've got a four year old that's brought into the emergency department by their parents after having a prolonged seizure lasting 20 minutes. Child has a history of well controlled epilepsy and has missed their last two doses of anticonvulsant medication on examination. The child is still unconscious and has ongoing tonic chronic movement. The blood glucose level is 4.2 and the temperature is 37.2. What is the most appropriate next step in the management? And I'll pop the pole up? Ok. Great. I can see some answers coming in. So just go through an explanation. So kind of a structure with your sda s point out that bring out the key information that they're giving you and try and get each um part of the question. Um Each option, sorry of the answers to fit to it. It should fit and sort of answer every part of it. If something seems not quite right, then it's probably not it. So the key things with this one, we've got a prolonged seizure. Um and we've got ongoing tonic clonic movements. Um So the correct answer is on the screen. So we need LORazepam and in pediatrics, it's not 0.1 mg per K IV kind of the explanation. So this is status epilepticus. This is something very important to be aware of. Um so defined by a seizure that lasts more than five minutes or recurrent seizures without regaining consciousness in between first line treatment is your benzos to stop the seizure. Um LORazepam is the preferred choice as it has a longer duration compared to diazePAM. Um In this case, the blood glucose level is within normal range and there was no indication of meningitis at that point. So lumbar puncture is not indicated, neither is given glucose. Ok? I think we're doing ok for time, our next condition is DK A. So kind of some of the pathophysiology, things that are important to be aware of to start off with um to ketogenesis. This kind of process will occur when there's insufficient supply of glucose. So the glycogen stores become exhausted and the liver will then take fatty acids and convert them to ketones to use as fuel instead. So this production of ketones, it's important to get your head around and remember um in normal healthy individuals, this is not a harmful process. This is not something that's just happening in diabetics, that's very dangerous. It isn't normal. It occurs under fasting conditions or on a very low carb high fat diet. Ketone acids are normally buffered by bicarbonate, produced in the kidneys. So then that stops your blood from becoming acidotic underlying pathologies such as type one, diabetes will cause extreme hyperglycemic ketosis. And that's what results in the metabolic acidosis. That is the life threating element. So, pathophysiology, this DK A occurs if there's not enough insulin to use and process glucose. The main problems. Um and these three are really important to remember is you get ketoacidosis, you get dehydration and you get a potassium imbalance. So I'll go through those now. So in ketoacidosis, we spoke about those kidneys producing a bicarbonate buffer for the ketone acids. And that keeps your blood in a normal ph range over time, you'll deplete the bicarbonate stores, it will all be used up and that causes the blood to become acidic, dehydration. Um essentially occurs because the kidneys are overwhelmed by the high sugar levels and more glucose will be draining into the urine. This draws the water out um through a process called osmotic diuresis C. This is what causes the polyuria symptoms that you may hear of some patients um presenting with when they're first diagnosed and it can result in severe dehydration that dehydration simulates the first center. And that's how you get the polydipsia as well. And finally, the potassium imbalance. So insulin drives potassium into cells if you think about it. Um in terms of your management as well, you can link this to when you've got hyperkalemia. How do you manage that? And what's the role of insulin in that? So, insulin will drive potassium into cells. Um Serum potassium in DKA can either be normal or it can be high. Um the kidneys will continue to balance um blood potassium and potassium will also be excreted in urine as well. Um The total potassium will be low as no potassium is being able to be stored into the cells because there's no insulin driving potassium into the cells. When the treatment with insulin starts, the patients can actually develop a severe hypokalemia, which can lead to fatal arrhythmias. So, the most dangerous aspects are the dehydration, acidosis and potassium imbalance. If you can kind of get your head around the pathophysiology a bit, it might take a few times going over it. It does then help you out with the management as well. Because if you start to think about what's happening, you can then think about what it is that you need to correct. So your priority in DK A is always fluid resuscitation to correct dehydration, electrolyte disturbance and acidosis. So that's what we're trying to do. Then you start to think about your insulin to allow the cells to start taking up glu glucose and stop the ketone production. So the presentation um patients will present with symptoms of the underlying hyperglycemia, dehydration and acidosis. So again, it always comes back to those three things. We may have altered consciousness levels, nausea and vomiting sort of the reports of weight loss polyuria and polydipsia if it's less severe or you may have, um, a patient or a family member that's also then able to, actually, they're very unwell now that I have noticed they've been losing weight recently or they do need to go to the toilet a lot more. I found a lot of, lot of empty water bottles in their room, that type of thing. Um, and tachypnea is also a very common one, especially in Children. And this can lead to patients being treated as an acute asthma attack initially. So just be aware of that. So, diagnosing A DK A, there are local criteria at each of hospital, but in general, you've got um the high sugars normally above 11, high ketones greater than three and then a ph lower than 7.3 or a bicarb, that's greater than 15. Again, just something to learn or vaguely be aware of because you'd probably be able to spot in an SBA question. Oh, that sugar sounds a bit high or those ketones sound high that bicarb is sort of too low or whatever it is. So there's two pillars to management. Number one is correcting dehydration and number two is your fixed rate insulin infusions. Um So that's correcting the issues of dehydration. Um and the ketones and then also allowing those cells to use glucose again and switching off that ketone production that's so dangerous. Um And just a note at the bottom, um the guidance does change all of the time about being fluid liberal versus fluid restrictive. Um Currently in my trust anyway, we're moving towards being currently a bit fluid liberal. So what this means is that all Children will receive a bolus of fluid on admission and if they remain in shock, they will have further fluid boluses the theory behind being more fluid restrictive, which you might see in a lot of textbooks is um correcting faster does increase the risk of cerebral edema. Um So we're aiming to correct that dehydration evenly over 48 hours. But sort of in practice, you do tend to initially give a fluid bonus and then you can slow down once you know that it's definitely DKA that you're managing. So the four phases, as I've kind of said, correction of shock, then your maintenance, fluids, your IV insulin and then when they're able to, you're looking at your subcu insulin, there are however, some other important factors just to keep in mind, um Is there an underlying trigger that's going on? Do they also have an infection? Are they also becoming septic? Then we need to make sure we're also giving antibiotics. We need to prevent hypoglycemia. The last thing we want is to be cracked and everything, send it to you far the other way. So when those BMS fall below 14, we will be putting up IV dextrose um potassium. So once you sort of know that the potassium is at a normal level. You will start adding potassium to IV fluids as you would with regular maintenance fluids as well. And keep close monitoring of that serum serum potassium very closely. As I said, these patients can quite easily become hypokalemic as we switch everything back on monitor very carefully for signs of cerebral edema. This is something that is especially important in pediatric cases. You won't hear about it as much in adult medicine. Um But it is something to be very aware of in pedes. Um and then monitor the glucose ketones and ph it's kind of self explanatory to assess the progress. And this will help you decide when it's safe to swap a patient over to subcut insulin. And just because I've mentioned it a lot. Um cerebral edema, Children in particular with DKA are a very high risk of developing it. It's essentially that combination of dehydration and high blood sugar causes water to shift from the intracellular to the extracellular spaces in the brain. As we rapidly correct that as we're correct in shock, it causes a a quick shift in water from the extracellular space into the intracellular space. Um it causes edema within the brain cells. Um So how we monitor for this is uh neuro ops. Um You look for any signs of cerebral edema um and be very concerned if a patient develops a headache, has any kind of altered behavior. Bradycardia or changes in consciousness and to manage this um you slow down the IV fluids. So the fluid um resuscitation is what's causing the issue. So we slow that down and you can use um Mannitol and Hypertonic Saline as well. Ok. So I know we're going through a lot tonight. I'm hoping to just kind of whistle stop tour through some of these main conditions, the slides and the recording will be uploaded for you as well. So you can break things down a bit slower. And as I said in the start, I'm happy for you to email me if you have any questions. So, sepsis, um a child with a likely infection and signs of an organ dysfunction or shock with thinking of sepsis. Um The younger the child, this is kind of a running theme for most of these presentations. But the younger the child, the less specific and obvious the symptoms may be and keep that low threshold always. So this might not be coming across too well. But essentially this is um a very simplified version of the pathophysiology. So you've got your immune cells that are identifying that there's a problem as sending off this cytokine cascade and that's where you get your interleukins and your TNF. Um It all brings it back to your preclinical medicine. So don't worry too much, but it helps with a bit of understanding. Um the nitrous oxide is what then causes the vasodilation of vessels. Um You also have the cytokines axin, which increases the permeability. So, fluid is leaking out, you have a decreased intravascular volume and then the surrounding edema from that fluid coming out creates the space between blood and tissues. So that reduces the amount of oxygen that's reaching the tissues. And then if you then imagine that that tissue is a kidney or another organ, that is sort of that organ failure that you see with sepsis. So it's a very heightened version of your immune system responding to an infection. And this is just a diagram again, if it helps you, then great, take a screenshot. If it doesn't, don't worry too much, people learn sort of very differently with drawing things out. Um I quite like sort of drawing things out on flow diagrams like this, but don't worry too much. Um But this idea of D IC disseminated intravascular coagulopathy. Um So we've had the activation on this, on the left side, the activation of the intravascular coagulation. You've got platelet consumption, the coagulation factors and the fibrinolysis. This decreases your platelets in, but increases your D dimer. And there's also some prothrombin and um PT and A PTT um will go up which you'll see on blood test and this gives you your impaired coagulation and bleeding. Um on the other side, probably to be aware of, more importantly is how we get the multi organ ischemia or failure. And that's due to endothelial damage leading to microvascular thrombosis and this leads to organ failure. So in the chat, are you able to put any signs of sepsis that we may see in a child? So any signs of sepsis that we may see in a child? Yeah, great fever, fatigue, decreased appetite, continuous crying, tachypnea. Excellent. Ok. So this is quite a long list, but essentially what you guys have said in the chat is the crook of that um always observed from the end of the bed, you can get kind of an idea your clinical judgment. Does the child look well or unwell? And are their basic observations normal for their age or not? Have they got or the basic test that you do the same for an adult? So the cup refills things like that is what is that like? Has it been reduced? Have they had changes in behavior feeding? Are they crying continuously? Are they inconsolable? Is their consciousness level? Obviously, this is a more extreme, changed again, reduced body tone. This would be more emergent if there's a reduced body tone as well. Are there any skin changes that you can see? Do they look sinos in any way, any mottling of the skin? Are they a bit pale or ashen at all? So, a septic shock, this is the idea of when a sepsis. So the infection has led to cardiovascular dysfunction. So we have a fall in the arterial BP that leads to organ hypoperfusion and an increase in blood lactate as anaerobic respiration begins. So that kind of little flow there. When we treat septic shock, we want aggressive IV fluid resuscitation. This improves BP and also tissue perfusion. Um if they fail or fluids fail to improve the BP and the lactate level, then escalation is always required. This will relate to both pediatric and adult medicine. If you're not able to keep the BP up, then we need to be thinking about a, using a bit more. Again, I'm just gonna kind of skip through this quite quickly. Um Either you can take these from the slides or from the nice guidance itself, but it gives you a traffic light system for recognition of serious illness. And this is for when you've got an under five year old that's presenting with fever. So we're looking at the low risk, the intermediate risk and the high risk of that this patient maybe septic, um looking at a couple of different things. So you look very low risk would be um if a patient has a normal color for them. Um But your high risk on the other end would be if they're pale mottled or ashen blue, so that if they're cyanosed, um activity ranges from their responding normally and staying awake. Um they're quite content, they may be crying, but it's a strong normal cry um or they're not crying at all. And then your high risk would be no response at all. And then they might not be waking at all. Or if you are able to rouse them, they don't stay awake. And that cry might be weak or high pitched or even continuous when looking at respiratory. Again, the low risk, quite self explanatory. You don't really have any concerns on the high risk. And that's when you've got your massive tachypnea. Um, you might have moderate or severe chest in drawing some grunting and sort of in the middle. You have a bit of tachypnea, you might have oxygen saturation that are a bit low. There may be some crackles on their chest, sort of pointing to signs that there is an infection, circulation and hydration. Um low risk, everything normal, high risk that reduced skin turgor in between. You might have a bit of tachycardia. The cut refill is increased. They may have, they might be a bit dry on the mucous membranes. They might not be feeding very well and the urine output may be reduced and then your other signs um is more towards the intermediate and high is thinking about the temperature of the child. And how long has the fever been going on for your extreme as we spoke about earlier with meningococcal disease. So it have they got a non blanching rash, they got the bulge in front of nos. Are they having seizures or any other sort of neurological signs as well? Your immediate management. Um So you will all know about sepsis. Six. especially in adults, there is some choice to do adopt sort of a pediatric sepsis six. idea um that the key sort of management points are high flow oxygen gain some kind of access and take blood. So you can send those off including cultures, um give antibiotics through whatever um access you've got either IV or IO fluid resuscitation. Um So this is aggressive fluid resuscitation in the case of sepsis involve your seniors early and consider ICU support early as well. Um If you've given 40 mils per kg of fluids and they've not um returns their normal physiological parameters, consider ICU admission, um early intubation in these cases does save lives. So then your further management, once you're kind of have your patients stable, um you may perform sort of any one of these or a couple of these depending on what you think the likely source might be. Once you start working, you'll hear a lot about sort of infection or sepsis of unknown origin. And your generic kind of infection screen will be um including sort of a chest X ray and normally a urine dip in adults. Um So it's these type of things sort of if you're sure of where the source of the infection is or you're not. Um And then once your cultures are back, you can then change your management and your antibiotic choice based on the presentation that you've been given. So it's been quite a while between questions. So we've got a third question. So we have a two year old this time who has sudden onset wheezing, swelling of the lips and tongue and difficulty breathing shortly after eating peanut butter. Um, the child has no previous history of allergies. However, on examination, they're distressed and tachycardic and hypotensive. Um What is the most imp appropriate first line treatment for this child? Ok. Moving on. So, yeah, we've got sort of these signs or these points within the stem that are pointing out to that this could be anaphylaxis. Um Just be aware that this question has kind of made it quite obvious cause it's given you a trigger of a peanut butter sandwich um in your exams and also in sort of real um life practice, it might not be that clear as to what the trigger has been. Um So you may have a similar question, but without the shortly after eating, it could actually be based on a child that's already in the hospital being treated for something and the trigger is antibiotics that they're having um or a new medication. So anaphylaxis. So we say I don't have many slides on this because the best way to revise is look over the algorithms for treatment and key point number one always remove the allergen often, especially when it occurs in hospital. It's a drug that we are giving. Stop the IV straight away. Even if you don't know if that's the cause, stop it, get early help. Um, the IM adrenaline immediately will treat the airway breathing and circulation problems. So when you're thinking of your A two E, um that's what, how you're managing those, um, do not delay treatment for com um cause you've got a lack of complete history or definite diagnosis and repeat if the features do not resolve again. I've had a case where we had a patient with the symptoms that we were a bit unsure. She ended up having um two lots of IM adrenaline. It turned out not to be um anaphylaxis. But if it had been and we'd have delayed that, then that would have been more dangerous. You can then monitor, you can then investigate further. So if you look this up yourselves, but this is sort of the algorithm. Um It gives you an idea of what to look for. Um making sure you're calling for help sorting out that trigger, given the iron adrenaline, making sure you've got an airway and high flow oxygen. Um and make sure all the monitoring is in place to get help someone else to do that for you. Um If you don't have response, then you repeat the im adrenaline a adrenaline after five minutes, you can give fluid boluses if the blood pressure's dropping. Um And if there's no improvement despite two doses, um then you follow the guideline for refractory anaphylaxis. So, refractory anaphylaxis is when there is no improvement in respiratory or cardiovascular symptoms despite two appropriate doses of adrenaline. Um So in these cases, you'll give rapid fluid bolus and you start an adrenaline infusion. But most importantly, keep giving im adrenaline every five minutes until that infusion has been started and is established and going through. You don't want to be going more than five minutes without them having any. And there is also another nice guideline for that on the recess council website. So fourth question, a nine year old presents to the emergency department with vomiting, deep, rapid breathing and confusion. You've got a blood glucose level there at 28.1 and arterial blood gasses with a ph 7.1 and bicarb of 12. The patient is dehydrated and her heart rate is 100 and 20 BPM. Which of the following is the most important initial management step. Oh Shadow pole and ok, so we actually have a couple of different answers there. Um If anyone's brave enough to share sort of why they've ruled out a certain answer or why they've picked the answer they have. Um If you can write that in now, I'll give you a couple of minutes. If not. No, don't worry. Ok, so the key sort of thing in here was about the blood glucose level and you've also got blood gas results there as well. Um And the correct answer is um IV Saline. So the explanation for that is um these, this is a presentation of DKA. So how we get into that is vomiting and altered mental status of confusion. They are common symptoms and that's due to the metabolic acidosis and dehydration. You have the coal breathing, which is a compensatory mechanism for metabolic acidosis. A marked hyperglycemia characteristic in DKA and arterial blood gasses showing a low ph and low bicarb um which confirms the presence of metabolic acidosis and ketoacidosis. dehydration is common due to that osmotic diuresis that we spoke about and tachycardia due to dehydration and compensatory mechanisms. Um As we've covered earlier in DK A, the most important first step is rehydration. Um So, correct the rehydration, restore that circulatory volume. Insulin is then initiated after food replacement. Um The potassium supplementation option is indicated once you have this confirmed serum potassium levels to be normal or low. Um And then a lumbar puncture is not really indicated in this case because it's not a suspicion of infection such as meningitis. We're quite clear that this is likely DK A I will say that was our last question. So we've kind of got through all of that in good time. Um The questions sort of when you've just spoken about DK A, they might be feel like they're a little bit simpler to answer, but just make sure you really revise those key points so that you're able to identify the condition and you know, the management when you're sort of an hour into an exam and you've had to be thinking about a lot of adult medicine because you do have to switch your thinking a little bit. Um, key points to remember, uh presentations of emergencies in pediatric cases can be very different and at times very confusing in Children. Um they may not present sort of with classic symptoms. It may just be a slight indication that they're a bit more tired. Um always ask for senior help and sort of early intervention, don't delay any treatment because you're unsure what a diagnosis is. Start the treatment, do your investigations and move on from there. Good in just under an hour. That's been sort of some of the key presentations you need to know for the UK MLA on pediatric emergencies. Um, if you have any questions, you can email me at any point. Best of luck with the rest of your revision and make sure you fill out the feedback form and that will get you your certificate as well. Um, I'll see you at the next.