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Ok, thank you. So, hi, everyone. Um Thank you so much for joining us again this week for our second lecture of the series. So we have doctor ran with us today to give us a lecture on the approach to a sick child. So, um if you have any questions, please pop them into the chat and we hope you enjoy the lecture. Perfect. Thank you everyone for coming to uh to listen to me talk. Um So today we're gonna have a quick chat through the approach to the sick child. It's gonna be a very quick whistle stop tour through most of pediatrics and we're gonna do it through a case based approach. So generally quite high yield, um high yield topics that are quite relevant to your revision, but also to your future as junior doctors and the basic things that you might see in any walk of life uh when you encounter Children. So, uh this is me on a good day. Um I am teaching fellow based at Saint Mary's, I'm also a pediatric registrar, um working at the moment in neonatology. Um That's my email. Please feel free to um just send me any questions, um and also drop any questions in the chat at any point in time. Um We're gonna mostly talk a little bit about about kind of a lot of the high yield things that you tend to see and a lot of the common presentations that you'll be faced with in pediatric A&E. Um, we will branch out a little bit into neonatology and just talk about the common things that we might see as um neonatal doctors and link it all back to bread and butter, things that you will need to be thinking about in terms of presentation, examination and management. Um This can all pretty much be underpinned by a few um basic differences. So through each case, we'll talk about the physiological differences that we see between Children and adults, we'll talk about how you might do an ABCD E assessment, thinking about common red flags that we might come come across and general clinical cases. Along the way, this kind of brings us into critical illnesses in Children and how we manage this from um not just from the initial primary care point of view, but actually in tertiary pediatric units, thinking about intensive care management and um strategies and how we do with these Children. It's important to think about the leading causes of mortality in Children and how this changes over time. So this is quite a useful um slide which has been presented um by the R CPC H. So uh the Office for National Statistics year on year. Um they basically release statistics on why Children die. And the things that we can see that are very, very different in older Children in the yellow, for example, is the influence of chronic disease. Um So for example, pediatric oncology, congenital heart disease, respiratory disease, um and and and issues with the CNS. But besides this, in the younger Children, we tend to see things such as infections and accidents, actually been quite a common cause of mortality and morbidity. So it's always important to remember that actually the changing landscape of pediatric health care, at least in the western world. And what we're starting to see even in developing countries is as we get better at treating the acute conditions, we starting to see more and more acute on chronic presentations. So it's always worth bearing in mind that whenever you have a child presenting to you with an acute problem, you do also need to screen for underlying um conditions. So whether this is immunodeficiencies, for example, whether this might be a red flag symptom for something such as a pediatric malignancy. So thinking about the underlying processes that we tend to see, we know one of the things that's often hammered home a lot in um in pediatric uh life support courses are the different modes that lead to um cardiac arrest and death. Generally speaking, you have cardiac failure and respiratory failure, respiratory failure or respiratory arrest tends to um preempt the cardiac arrest. And when we think about the different types of processes that occur in Children and disease processes that we tend to see more often than not. It's more likely that you will see a respiratory problem rather than a cardiac problem. The reason for this is often because we tend to see that uh older adults or as you, as you get older in life, you start to accumulate more and more lifestyle related disease. So this can be things such as subclinical atherosclerosis, ischemic heart disease, the impact of diabetes and hypertension. Whereas in Children, although you do sometimes, for example, you may see hypertension and you may see fomentation of diabetes. It's much less likely that you will see lifestyle related disease in Children. Therefore, it's more important to think about your respiratory pathology and acutely escalating your treatment earlier from a respiratory point of view, rather than thinking of cardiac causes. Now, you can, you can split this up even further into thinking about airway obstructions and issues such as let's say foreign body obstruction, parenchymal disease, which deals with the lungs themselves or or respiratory depression due to the effect of toxins or drugs. Similarly, when we're thinking about cardiac failure, you can have uh hypovolemic um fluid loss. So for example, this could be due to interstitial loss or secondary to sepsis. Equally, it could be due to trauma or burns or D NV. Um and then also thinking about uh cardiac pathology or renal pathology in terms of the distribution of fluid within the various compartments within the body. Ultimately, what we're trying to pre naturally is death. So let's start with our first SBA. So you're minding your own business in pediatric A and a six month old infant presents to the P ZD. He's got a one day history of a barking cough and inspiratory stridor. And these are the observations that you notice. So she, you noticed that, sorry, you notice that he has subcostal recessions, a heart rate of 100 and 20 respirator rate of 50 oxygen saturations of 92%. So what do we all think is the next best management step could be salbutamol nebulizer driven in air oral dexamethasone. A chest x-ray 15 L, high flow oxygen, oral dexamethasone or IV antibiotics. Feel free to um drop your answers into the chat or um vote on our poll and I'll just give you a few seconds. OK? So we'll just try and see what you guys have on set. OK. So we've got a good mix. We've got a mix between B and D. So just going back to our question. So B and D, so it's a good thought. So, trick question I've gone for D and there are a few things that um that actually will point us in the right direction. So, um most important things, think about age. So think about how old your child is and whether they're in the right age group for something such as creep or whether this is bronchiolitis and stridor. So, Stridor points towards some kind of airway pathology. Now, there are a few different things which are slightly abnormal. So our the heart rate is still quite high for a six month old. So they're quite tachycardic and a respirator rate of 50 is still quite high for a for a six month old. So with tachy and tachycardic with saturations of 92 and the most important thing here is to is to realize that not only do we have this degree of airway compromise, but also they're hypoxic. So just thinking about how unwell we expect this child to look, um I would think about doing it from an ABCD E approach, but most importantly, managing that hypoxia with high flow oxygen, oral dexamethasone is the important treatment to give. But it's important to realize that if we're giving oral dexamethasone, there are other agents that we can use at the same time. Ultimately, yes, airway compromise will um will be the most important thing, but we have to think about it from a holistic point of view. So you would not just give dexamethasone alone to a child with sat of 92. Um Now, when we think about croup in general, it's important to think about it less as um as just one specific disease in isolation. But to think about airway obstruction as a continuum. So, the reality is when you see these Children in A&E and you don't have that much of a history. It's difficult to tell whether or not they've had a foreign body inhalation or whether or not it's croup or whether or not it's bacterial tracheitis, um, or even epiglottitis. Now, there are things that are in the history that might be able to guide you one way or another. So things such as vaccination status, if the child is drooling, for example, has a hot potato voice.