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Hello, everyone and welcome to our, er, pediatric Emergency Medicine series. The first five minutes with Katherine Derry. What we're gonna do as always is we Catherine's gonna chat to us. We're gonna pop questions in the chat on the right hand side. Pop any question you have, no question is not worth putting, put them all in there. Um, and she'll get round to them maybe as she's going or afterwards, depending on where she is with her talk, she'll get round to answering all those questions at the end. You'll have your feedback form and once you've completed that you'll have your attendance certificate. All right. So I'm not gonna chat anymore cos I'm really interested in this one. So, um, we're gonna sit back and watch right over to you, Catherine. Hi. Good afternoon in England. I'm not sure what time it is with you. It's a real pleasure to be able to speak to you on this forum. I've not done this before, so do so do bear with me. Um, I am a consultant pediatrician in the UK in the south of the UK. Um, in a place called Plymouth. I've been a consultant pediatrician for about 14 years and a pediatrician for about 25 years. I've never had the privilege of working in a resource poor country and I have certainly never worked in a war zone having said that, um, between us, we share an awful lot of similar patients and what I would like to do with you today is to talk very much as a general pediatrician. Um, I've gone through my talk as much as possible trying to find cases that we will share similarities with. I'm not going to talk about malaria or TB or HIV, but we will have a lot in common. This talk is very much designed for doctors who maybe aren't so familiar with pediatrics and are coming into it. Recognizing um how scary pediatrics can be if you are an adult physician. Um it's very much designed to help you revise an emergency approach to managing the very sick child and to recognize the very sick child and hopefully to highlight differences between adults and pediatrics as we do it. So, first of all, I suspect many of you are either medical students or come from a predominantly adult background and you may feel just a little bit anxious about pediatrics. What? Um sorry, the last thing to say is normally I give this talk or a similar talk in a very small interactive environment that's going to be difficult to do with more than 100 of you on the talk. I would really love it if you could have a pen and a bit of paper by your side. And when I ask a question, write down your answer, no one else can see it. So nothing you will say is too stupid, but it will just help to keep you really engaged with the talk. So, first of all, why are we a little bit anxious about Children? Why are Children different from adults? So, just have a couple of minutes of writing down as many differences as you can think of. And then I will go through some of the ones I can think of. And if you want to put ideas in the chat, you're very welcome as well and bring them up. So I think perhaps the most obvious thing is they are small, aren't they? They're much smaller in the UK, the average weight of a term baby is three kg. I'm not sure what it is with you, but it's much smaller than an adult, isn't it? Um Just to put that in perspective, do you know what the blood volume is of an adult without being personal? What's your blood volume? It's gonna be about 5 to 6 liters, isn't it? In a little baby? It's 80 mils per kilogram. So if you have a three kg baby, that's 240 mils of blood, that's not very much is it? And you can see if you're shaken, for example and have 24 mils of blood, um, bleed into your head. You might be in shock with 10% of blood loss with nothing visible to show very different from adults. Or we tell our junior doctors if you make too much mess, putting in Cannulas or umbilic venous catheters, for example, and leave too much blood around. That may be a significant amount of the baby's blood. So somebody said, because babies deteriorate quickly, that's very, very true. Adults deteriorate in a very long, slow, visible decline normally and make quite a lot of fuss over it, don't they? Whereas Children may compensate, compensate, compensate and then suddenly deteriorate. You're absolutely right. But in every illness, there is scope for predicting it, which are the illnesses where babies or Children suddenly deteriorate. What are the vital signs? What are the symptoms? And that's something that we'll very much address today. Um, somebody, you said that they can't tolerate severe conditions like adults, I'm presuming, you mean they lose heat, they get cold quickly. Look at that baby's body surface area. It's much bigger compared to the baby's mass compared to his mother, isn't it? Um, and they lose water very quickly as well. Um, Children have a different body physiology. They do, but they are also still people, an awful lot of what you will have learned in your adult work or at medical school is applicable to Children. They're not aliens, they're not that different. Their electrolytes are usually not the same, their full blood counts aren't that different. Their physiology is not that different. However physiological upset might show differently. So children's observations will be different from adults. And it's really important you have some sort of record either on a phone or a bit of paper with the normal observations on the child that you can refer to. So, online, there are good resources for this. For example, the A PLS has a nice table of normal observations, but just to get your eye in what is always a high respiratory rate in a newborn, in a baby under three months of age, what? It's always high? Can someone write that down for me? So 60 above is always an abnormal rest rate. It doesn't mean that that 50 is normal, but 60 is always abnormal. And from a heart rate perspective, 100 and 60 is always abnormal. Again, it doesn't mean that 50 is normal. It doesn't mean there's not a good explanation for 100 and 60 a fever or a baby crying. But but dismiss those normal observations at your peril, those abnormal observations at your peril. Somebody said anatomy is different in babies. It is a little bit, isn't it? Um For example, that's significant. If you're trying to intubate a baby, I imagine many of you have intubated adults and it's not difficult. Is it big plastic tube down a massive great hole? Little babies? It's difficult. Their occiput is really big, you can easily hyperextend or hyperflex the neck. They have a lot of soft tissue. The tongue is very big. Older Children might have teeth that are easily dislodged and the vocal cords cells are very reactive, can easily go into spasm and the trachea is really small. I'm sure many of you had put um cannulas into adults and babies. It's, it should be easy, but it's not, it's quite difficult. Even this baby is lovely and podgy. It's hard to see the vessels, isn't it? So, anatomy is a little bit different. And certainly there are anatomical differences that are relevant when you're doing x-rays, for example, like that, quite a few of you have mentioned communication and that's really key, isn't it? And so much of pediatric work is really honing your skills of observation, which you should use in adults, but it's in kids, you just have to because if you're not observing, you will miss huge amounts of the information Children do communicate. But the way a six week old communicates compared to a 15 year old, for example, is very different. And trust me, you may have a 15 year old who looks like a man, but they will think and communicate differently from a man. Unless you ask them what you're thinking, you won't have any clue about that. Um Likewise, they may have very different conceptions, preconceptions in their mind. They may be absolutely terrified and it might not be immediately obvious to you as to how they're scared, you need to ask and find out and when you give them information, you will need to speak in a language or body language that's appropriate for the age. And really, that's only something you can learn from. Experience, a very valuable part of the job. What else have people said? Nobody's mentioned parents yet that I can see? Certainly in the UK and I'm sure in your country, parents are an absolutely key part of the medical consultation of a child. Usually a very, very positive part. They know their child very well and dismiss their concerns at your peril. Really listen to them, make sure they're part of the consultation in a multidisciplinary team equal to yourself. Having said that don't let the child's story be filtered by them too much. If you watch good pediatricians at work, they very much keep the child at the center as much as you can address to the child, bring them the parents after and remember just occasionally parents do harm unfortunately, and that will go in all our countries. What else is different? Well, disease, disease, your differentials are different, aren't they? For example, in this country it's getting winter now it's getting cold. We're getting lots of Children coming in with viral infections. If we have a 80 year old who comes to an A&E with three days of snotty nose fever cough and on day 33 is deteriorating with increased work of breathing and low saturations. What, what might be the diagnosis, be free to say, what would be the diagnosis in your country? Just, just write those down. What are the common diagnoses? I think you're welcome to put it on the chat or just on a bit of paper next to you. So, in an 80 year old, I imagine it could be a viral pneumonitis. It might be a bacterial pneumonia. It might be a deterioration of COPD. It might uh you might have an underlying um cardiac disease, which is probably ischemic, isn't it? There? Um may be carcinoma in the background. I'm sure infections play a bigger part in your own country, but there's a fairly even spread of diagnoses. What about you have exactly that same history in a four month old baby, a four month old baby with snotty nose for three days, cough, bit of fever and now increased work of breathing and decreased saturations. Do you know what the most likely diagnosis is? And this will apply to both our, all our countries write it down. Commit yourself here and I'm sure this is the case with you in at certain times of the year, it will be viral, bronchiolitis. So, inflammation of the bronchioles caused by a virus, many viruses do it. But here we particularly scrub a struggle with RSV respiratory syncytial virus largely because we don't have any sort of immunization program against it though one is being evolving in at the moment, but other viruses can do it. Rhino virus, COVID, um A, a adenoviruses, lots of viruses will give you that picture. And that is way more likely a diagnosis than any other in our country. Having said that if we knew that was the diagnosis, we don't really need to examine the child, would we? But of course, it's not definite, it could be a pneumonia and if you're malnourished, you're much more likely for it to be a serious bacterial infection. It could be first presentation of cardiac disease and in babies, unlike adults, that might be congenital abnormality, um It, it could be because of other congenital abnormalities, tracheal esophageal fistula, first presentation, cystic fibrosis, congenital emphysema. So you see a very different, a very different differential diagnosis and a very good way to build up pediatric knowledge is every presentation you see, learn the list of differentials, what's the most likely differential and what are all the other possible differentials? Because if you do that when you approach in your detective way and that's what we do to be healers to come up with the right diagnosis, then at least you'll be thinking of all the diagnoses. It's a good problem place based way to approach pediatrics. But certainly kids, you will have way more infectious diseases. You'll have way more metabolic abnormalities which tend to have worked themselves through adult and congenital abnormalities as well and they are particularly prone to nonaccidental injury to trauma as well. I think those are main differences. Has anybody else added anything? So, the weight body surface area, I think we've talked through main differences there. So, in pediatrics, there are three main skills in your job. To be honest, first of all is the ability to recognize the sick child. So, the pediatric patients, these nice sheeps standing on the cliff, this one's kind of fine, this one's really poorly and this one's so poorly, they suddenly decompensated and once they decompensate, it's very difficult to get them back again. Your job is all about recognizing and treating the sick child before they get to the edge of this cliff. Secondly, it's recognizing serious pathology, which of all those little babies with snotty noses and a bit of increased work of breathing, which of those are actually congestive cardiac failure or a nasty pneumonia as opposed to a mild viral bronchiolitis, which of all your little Children presenting with diarrhea and vomiting and dehydration, a hepatitis rather than viral gastroenteritis or have raised intracranial pressure or appendicitis. So that, that is your job. And then finally, as I'm sure you're all aware if they don't like you, if you can't communicate with them, they won't let you near them. Unlike your adult patients who are generally a bit more stoic and that's a very nice part of the job learning to communicate. So, in this talk, I'd like to talk you through some common general pediatric emergencies and give you a very practical basic emergency approach and in that revise the basic assessment of the child. That's what this talk is really about. And whilst doing that, we'll highlight further differences between adults and pediatrics. When I give this talk in the UK, it's very much for our junior doctors doing their first pediatric shift and I pretend this is their first pediatric shift. And the aim is to take the fear out of it is what can you do in the first few minutes of a child being ill? I'm not going to take you through the next hour or two hours. Cos each emergency is a talk in its own. Right. Let's, let's start with one you're probably very familiar with as medical students or adult doctors. So this chap is 15. He has a known diagnosis of asthma already. He's um, been prescribed medication and preventers. Um, but isn't very good at taking them. He's recently had a snotty nose and his mum has brought him in, um, albeit diff in difficulty because he is very combative and angry and is effing and blinding. Those are swear words we use in our country. I'm sure you have lots in yours. He is very agitated and cross at being there. Um You're, you're asked to see him, how, how are you going to assess this child? First of all, I want you to write down a few things. What is the most likely diagnosis here. Is there anything that worries you? And how is your immediate assessment going to play out if anyone wants to put anything in the chat you're welcome to, but I'm trusting you're all writing it down on a piece of paper. And what is the probable diagnosis here? What are you worried about and how are you gonna assess as child? So, I think everyone in agreement that the probable diagnosis is a viral exacerbation of asthma, isn't it? Probably. Yeah, it's possible. It's something else. It's possible. He's got a pneumothorax. It's possible this is a pneumonia, foreign body anaphylaxis, but none of that really fits with what I've told you already does it, it's probably exacerbation of asthma. Are you worried about this? Well, I I think you should be and that is because asthma very quickly is life threatening by definition. So using the BT S guidance for assessment of asthma, for example, if you can't speak in um more than single words, your SATS are reduced or you have any evidence of hypoxia that would all push you into the lifethreatening category. And that happens very fast. Why, why do you think this child is combative and anxious? Is he just a stroppy teenager? Does he hate his mum or does he hate hospital? Possibly? But it's probably because he's got low oxygen. He's hypoxic and that makes you feel most peculiar indeed. So this is hypoxia and this is probably lifethreatening asthma. So when you're assessing, I would urge you to have a basic emergency approach which involves first this eyeball assessment we've just done. Then it's calling for help. I don't know what help you will get in your country where you are, you'll know your own services. But we encourage our juniors to call a senior and they know how to do that whilst you're doing that, you make an assessment and you, we use and I urge you to as well. It will get you out of many, many difficult situations. ABC de as your assessment tool. A airway. This child is speaking in single words, albeit swear words and the phonation is normal and there's no stride or present. This child's airway is pot patent. We can tick the airway box, then B for breathing you should have in your, I should have written down how you assess breathing. But if you haven't just write the points for assessing b in this speedy sort of situation like this, so it's going to be looking at the work of breathing. And already you can see this child is sitting in a tripod position, isn't he? You can see he's got accessory muscle use. He looks like he's running a race in effort, isn't he? But he's just sitting there. Um And if you look closely, he's probably got subcostal underneath the ribs and intercostal between the ribs recession as well. He may have a degree of sternal recession and he may be tugging in his trachea as that accessory muscle use. He's probably got a fast respiratory rate. And you will know that by referring to a little bit of paper that tells you what's normal, but in a 15 year old, your ob should be pretty much adult and his rest rate might be 40 50. Yeah. Um, so resp rate increase work of breathing. Somebody's just managed to put a sats probe on him whilst he's got oxygen on him, the SATS are 92%. But before they put the probe on, they were 78% that goes along with a child who's very confused, doesn't it? You'll get your stethoscope and listen. If you look at this child, it's very hyperinflated, isn't he? Can you see the top bits hyperinflated? And that's a real sign of asthma and bronchospasm can get the air in, but it's really hard to get it out. Um And when you listen, you can hear entry up the top, but it's not very good down at the bottom. And that is inspiratory and expiratory. Wheeze just to just, just to get your eye and what's, what's the definition of? Wheeze? Just remind me, apologies if these are really basic questions for some of you. It's still good to remind yourself. So Wheeze is a polyphonic, usually expiratory sounds, but it can be inspiratory as well. And in bronchospasm, what you classically see is this prolonged expiratory phase or that increased work of breathing. So we have assessed breathing. And as part of that assessment, we know that the the inadequacy of breathing is having effects on this child. He's confused. He's probably tachycardic as well. So, assessment diagnosis first actions does anywhere worry you here. So do you all agree with me that this is lifethreatening asthma? This lad is one of those little sheep that is about to fall off the cliff. Would you a part of your first actions? Was anyone want to do any investigations here? Would you as part of your immediate actions? What would you do? We've called for help. You've assessed. What are you going to do next? Let's just go through that assessment. So you've done your assessment. What treatment are you going to give? Write down on a bit of paper, what you're going to give immediately first five minutes of this treatment to stop this, this child falling off his cliff. Sorry. So the treatment is call for help high flow oxygen and keep things calm, really calm. It will be very, very stressful. It might help to get your hands and with his permission, gently push down on that hyperinflated chest and then you need to give him bronchodilators and we give bronchodilators driven in nebulizer form. If you've got it, if failing that you could give in an air chamber, but a child this sick, you might really struggle to get enough in, in that form and the bronchodilators we all use round the world is primarily salbutamol. We can use Ipra cream as well. And in some places, we use magnesium though, there's not brilliant evidence for its use and this is what is going to save your child in the next few minutes. And you give the salbutamol and you give it again and again and again and most importantly, you don't just write it up and walk away. You ensure that somebody is tasked with giving the salbutamol effectively because in a child, especially a big boy like this who's combative, it will be very difficult to give potentially. And you can imagine the little tiny babies, it can be difficult to give as well. Our dose. If you can't remember, you give your adult dose, you give five mg of salbutamol via nebulizer. In fact, under the age of five, the dose is 2.5 mgs. But if you can't remember, give five, because once we've given 2.5 we're just going to give another and another and another. Um you give ipratropium up to three doses as well Atrovent if you can. And again, if you can't remember the doses go for adult, adult is um 500 under the age of five, it's 250 micrograms under the age of one. It's 125 micrograms. Ideally, wherever you work have these protocols um stuck up on the wall. So they're easily accessible. You can certainly give steroids but that's not going to save this child's life in the first five minutes. Is it much better to pour in back to back nebulizers? Don't delay nebulizers to get IV access though. You might need IV access to give an infusion of salbutamol here. It's all about giving him the nebulizers. So that will buy you time to get help and to get up your guidance on the management of asthma and the doses and management of asthma. Just, just talking through differences between adults and child Children. He's very much an adult case, isn't he? Oh, sorry, of course, Children will get little Children get viral induced bronchospasm, whether you call it asthma or viral induced wheeze as well. A few pitfalls with or a few differences between them and the management of bigger Children. They are very, very pliable chests. So you will see huge increased work of breathing usually unless they're are particularly malnourished. So have very poor muscle mass or have some of the neuromuscular problem. X premature spinal muscular, actually, cerebral palsy or something where they just might not be able to mount that respiratory response and they deteriorate very fast. Bronchospasm in these Children might present with wheeze, they'll have the hyperinflation, the prolonged expiratory phase, but they might not have those classic adult signs. They might have a chest that sounds more just full of crackles or you might not get any additional sounds at all. But if they look and the story fits with a bronchospasm reach for your bronchodilators before you reach for antibiotics, x-ray or other things. It's probably still viral induced wheeze. But they can look quite different and you have to be very, very careful that these Children are being that you're delivering the medicine that you're prescribing. Has anyone got any questions as we've gone along? It's very strange speaking to myself without um interaction. Is this helpful so far this approach, I'm gonna assume you'll say yes, let's move on to another case. So you've saved that child's life. One of your adult colleagues now has said, oh, I feel very comfortable with taking this on. He's really turned the corner and they turn the corner fast and you're asked to see this child who's in a corner with, with dad on his knee. This is two in the morning now. So this child has had a snotty nose and a very loud cough for a couple of days and has just woken up in bed with very marked increased work of breathing. Dad's worried that might have been some toys in the bed overnight and maybe a toy has gone down the wrong way. I'm going to show you the video when we practiced this earlier, you couldn't hear the sounds, but I, I might have to imitate the sound for you. Can anyone hear that? It's, and then can you see this child's drowsy, this tracheal tug? Can you see that sternum is going in and out. It's quite a lot of sternal recession. It's probably a little bit of subcostal recession isn't there. And if you could hear this child's doing this, yes. Have a think, what is the most likely diagnosis here? So, he's not particularly hyperinflated is he? But he's accessory muscle use. He's really working quite hard. And when you take observations, he's tachycardic, isn't he? His cap refills? All right. He is breathing fast. His saturations are not normal and he's got a low grade fever. So, just have a write down what is your probable diagnosis here? And what other diagnoses would you consider? Let's do that. First of all, I'm glad you can't hear him. It's a horrible sound, makes me anxious. So I hope you've got the probable diagnosis is C group laryngo trache, um malacia, um sorry, um laryngotracheal, my um bronchiolitis. So, inflammation of the entire respiratory tree, but especially the upper airway. Um usually viral. Um lots of viruses cause it, but influenza a particularly um again, adenovirus, Rhinovirus, we've seen COVID do this an awful lot in tiny babies and it's inflammation up here. And if you ever only have a very, very tiny trachea, you will remember the the relationship of resistance to trachea diameter. You can very easily with a tiny bit of inflammation, get marked resistance to breathing in, you can get poorly very, very quickly. And though this is a viral etiology, this child might be about to fall off the cliff. What makes me most worried is, look at those saturations. They're really low. That's not because this child's got bronchus spasm throughout the whole lungs. It's because they've got incipient airway collapse. They're about to die. He's also, despite all this increase in breathing, he's out for the count, isn't he? Which is probably a hypoxia thing as well. What else could it be? It could be um, epiglottitis or in countries where you've not got um, dip three vaccination. It could be um diphtheria. It's possible it's a foreign body or to wake up at two in the night with a foreign body with a history of fever and epiglottitis and diphtheria usually are pretty sick and it's hard to mount a loud cough. It's usually a very soft cough and you generally look more toxic if in doubt you give antibiotics. But what are you gonna do? You've got this child? How are you going to save this child's life? So, I want to, I want you to write down very quickly how you're going to do it. What treatment are you going to use? Just well, we do that, I suppose just to remind you again that ABC D um assessment A, we've really just got stuck on the airway here, haven't we? This airway is about to collapse. But if you go to B you can see he's got his tachypneic, his sats are low. There's all that increased work of breathing. We discussed but when you listen, breath sounds are vesicular with inspiratory and expiratory stridor. So, how are we going to treat it? We are going to treat it by being really, really calm. Yeah, it's frightening. It's calm. Everybody needs to keep calm. And then what saves his child life is adrenaline and ideally you give it nebulized, we give nebuli adrenaline 0.4 mils per kilogram. One in 10,000 in our country, the average child is 10 kg at the age of one. So at the age of one, that's going to be about four mils, isn't it? You have a ceiling of five mils largely because you can't put much more than five mils in a nebulizer. But that's what you're giving adrenaline. And in the situation a lot will go up your nose a lot will go up mum and dad's nose. Everyone feels a bit anxious, but it really does work and you might need to give several adrenaline nebulizers. You might find that the adrenaline works incredibly well. So just as a little bit of edema makes this child look ghastly, a reduction in edema can provide huge benefit, huge improvements, but very quickly the adrenaline will work wear off and you need to expect to give more than 10 minutes potentially. So at the same time as you give the adrenaline, adrenaline give steroids as well. They take longer to work maybe half an hour, an hour. Three hours, but at least they can start working. Um, oral dexamethasone is cheapest. Um, but it's the same efficacy as nebulized budesonide use what you've got and you drive that with humidified oxygen. You don't need to do anything else. If you're really suspicious, it's epiglottitis or diphtheria, you're going to treat that as well, but you will still give adrenaline steroids. It's airway as your priority. Ok. Ok. So let's go on to c the assessment of cab we've done with very sick kids. Let's look at another little child who's about to fall off their cliff. I'm sure many of you will be familiar with this sort of story. These two Children have both had four days of vomiting and diarrhea along with the rest of the family, but the rest of the family is better. They both had fever the first two days, but the fever has settled. Initially. The vomiting was very profuse up to 20 times a day, but neither have had more than two vomits in the last 24 hours. Initially, diarrhea was very profuse and green. There was no blood or mucus, but now diarrhea is just tiny, little squirts every few hours. Children seem very uncomfortable. Um, they're not drinking and um, mum can't remember the last time they weed. Ok. So write on a bit of paper, what is the most likely diagnosis? And I appreciate that might be slightly different depending which country you work in and then what are other possible diagnoses. Ok. So in our country, this is almost certainly viral gastroenteritis. We certainly get bacterial gastroenteritis as well such as salmonella campylobacter. It may of course be part of AAA wider infective condition, something you see hepatitis as well. It, it's possible there's something else going on like sepsis or an abdominal focus, but this is probably viral gastroenteritis and this child is severely dehydrated, aren't they? So if we're assessing this child? A Yeah. So already you've recognized this child is sick. So we're going to call for help. You get whatever help you need. You're going to assess a the child whimpers when you wake them up. Um There's no additional sounds on breath sounds airways patent, isn't it? And the child will open his eyes when wake, when waking up. Um B it's quite tachypneic respirator of 60. That's high, isn't it? And it's a quick sighing respiration. So it's not subcostal recession, not sternal recession, just vast sigh. And when you listen, um breath sounds are vesicular throughout with no additional sounds. You can't get a SATS measurement either because your probe is not working or P ETS are just really difficult in this baby. So let's move on to the assessment of see now, cardiovascular. So just write down what are the key components of your assessment of C in your notebook? So key components, heart rate number one. Yeah. And this child's heart rate is really high, isn't it? 100 and 80. And when you feel the heart, it's rapid and weak as well. Regular but rapid and weak cap refill. So, pressing firmly on the sternum for five seconds and releasing and counting the time for reperfusion. And this child is five seconds, which is very, very abnormal, isn't it? It should be less than two seconds. BP, systolic might be a bit low, but that's very much the last thing to fall. It's possible it's normal. Um And then the effect of perfusion, does this child look normal to you? Does it look like a normal one year old? The 10 month old child really doesn't. It's like you got a decreased level of consciousness as well, doesn't it? And none of those observations are explained by a high temperature because the temperature is normal. So this child is a child who's very, very unwell who's about to fall off the cliff probably because of dehydration. So, as long as along with dehydration, just now think, how do you assess fluids, particularly? What's your emergency fluid assessment? Just write down the key components of that. So the history it's got to be dry, hasn't it? Given the history? Um, a sunken eyes, you might pinch the skin and the skin stays up just like an old ladies. I've stopped doing this because my skin sometimes stays up and skin tur goes down. Yeah, maybe you can't see AJ VP. Not a reliable sign in these little podgy babies. Is it um, dry mucus membranes, dry tongue. You may have objective weights. Many babies have a weight measured from before and it was very obvious if you've lost one kg, then that will be one liter of fluid lost. Um And don't forget, sugar. So you've assessed this child. You're really worried. You think it's probably viral gastroenteritis could be other things, but they're, they're sick. Your first actions to call for help and you need to get fluid into this baby, don't you? That's going to be your life saving treatment, oxygen to help rep, perfuse the baby. The baby does anything worry you here. Yes, it does. Investigations. Anything we're going to do is an emergency. Be really nice to have a sugar, wouldn't it? And a gas if you can do it. But the sugar is the most emergency investigation here. So, assessing circulations as we've discussed your vital signs, heart rate, pulse volume, BP, what's the skin and mucous membrane perfusion like and organ perfusion as well? Assessing fluids. It's part of your ABC. Then you look at skin TGO just as we said, mucus membranes input, output the weight of the child and sugar. So we're going to give them resuscitation fluids in a child. This sick, you're very unlikely to manage this orally for a nasogastric tube. But if that really is all you've got available via an NG tube, but this child should be resuscitated intra um intravascularly or intraosseous. If that's what you've got, it needs to be um with um with an isotonic fluid. So we're still using normal saline in the UK. Ideally, you have something that's more compatible with a body such as plasma light or Harmans. You must never of course use water or dextrose which will decrease the plasma osmolality and just give you cerebral edema. So probably normal saline is what you're using. Be careful, the fluids are in date, the seals attach, but you need to give resuscitation fluids and you give a 10 mils per kilo bolus and then reassess and give again and again. So if this child is one, let's say normally 10 kg, you're going to give how much as a fluid bolus, just write it down. You're going to give 100 mils, aren't you? And you're going to give it as a bolus. If you have a bag, you could squeeze it. But ideally, you're going to get 2 50 mil syringes and push it in. You are going to check a sugar though. And if the sugar is low, you're going to treat the sugar as well. That's a separate thing from your fluid resuscitation. So if the sugar is low below 2.5 give two mils per kilogram of 10% dextrose as well. If you don't have that, you might need to give some sort of sugar into the gums of Glyco or, or Coca Cola or small amounts, whatever you've got, but that is a separate thing you're treating. Ok. And in dehydrated babies like this, they may need 30 even 40 mils per kilogram of fluid. Once you're up to 40 mils, you might need to um intubate and ventilate this baby. Just to give you an idea of severity. I think it's worth talking about fluids here because it's something that if done right can save children's lives and it's so often done badly and when it's done badly, using adult guidance, it can kill Children. So that's why I want to just talk you through calculating fluids in Children. So you give your resuscitation boluses immediately and you um and you assess after every bolus, then when you have achieved better perfusion, the cap refill is down to three seconds, the heart rate is down, then you want to um you want to put them on to a maintenance dose if they're able to drink of or you think you can do it by tube and they will tolerate that. That is preferable to intravenous. So go across to nasal gastric tube or oral as soon as you can. But let's assume you can't, you want to work out how dehydrated they are and what maintenance fluids you're going to put them on. Now, it's really worth having these sorts of calculations in your phone or on the scrap of paper or in a book you work with. But when you're calculating maintenance, food for Children, I'm Sure, you're all familiar with this algorithm. We use 100 mils per kilo for the 1st 10 kg. So this baby, a 10 kg baby, they will get one liter over 24 hours just as maintenance. Yeah, if there were 20 a 20 kg baby, they would get 1500 mils over 24 hours. Agreed, then you want to try and correct their deficits because you've not done that with your resuscitation fluid. You've just um improved their resuscitation state. The way we estimate percentage dehydration and it is just an estimate is pretty crudely actually, if you have a child who must be dry from their history, but is no signs of dehydration and is cardiovascularly stable. They will be less than 5% dehydrated if you have a child who must be dehydrated from their history and they have signs of dehydrated dehydration. Yeah. Poor skin tag or, or something, but are not cardiovascular compromised. They're between five and 10% dehydrated. Ok, let's take 5%. If they must be dehydrated, they have signs of dehydration and cardiovascular compromise. Consider them 10% dehydrated. Yeah. And then what you do when you're calculating their fluids is you calculate the maintenance fluids. So, for this sets for this 10 kg baby, we're going to give them 1000 a day and then we're going to add on their percentage deficit, their percentage dehydration as well. And the way we do that is, let's take those babies, let's say they were 10 kg and we're estimating 10% dehydration. It might be considerably more. But we'll estimate as 10, how much fluid is that baby down on just right on a bit of paper. I'll tell you. So that baby is down on about a liter of fluid. So the way we work it out, we imagine the child as a bag of fluid. So 10 kg, 10 liters of baby loveliness. And if you're 10% dehydrated, you've only got nine liters of fluid left, you're 10% dehydrated. So our aim is to add that deficit on to their maintenance fluids as replacement. And you can replace that as fast or slowly as you like better to do it slowly. Usually. So usually a 10% dehydrated baby, I would replace it slowly over 48 hours. So if I ask my junior to calculate fluid for this baby, I would expect them over 48 hours. I would expect them to say, well, they're going to need one liter for the 1st 24 hours, another liter for the next 24 hours and another liter to calculate their deficit and then divide that by hours. Does that make sense? So it's going to be in each 24 hours, 1.5 liters divided by 24? See if you can work out what that is and I'll tell you what the correct answer is. I'm very happy to answer questions on this. So this is tricky. There's lots of guidance out there. So the first few times you do it do it properly. And I can't emphasize enough using the right fluids in the right amount, save lives, giving too much fluid or the wrong fluid causes cerebral edema or inadequate hydration and Children die. So you should have worked out if we're um correcting that percentage dehydration over two days, 48 hours. That child should be getting 10, 62 mils an hour. As starting. Then you need to calculate replace losses and you need to reassess very regularly. That's just starting. Nice guidance. Have really good guidance to help support you with all of this and this is very much set up for a resource, poor setting as well as richer settings as well. You're probably a bit exhausted on this shift, shall we? Um, I've got two more cases if you can bear it. Let's do this one quickly. This one's crept up on you while you've been managing all those sick, sick patients. It's your neighbour's child. They popped across the board to you and said I'm charging or they've given you a call in the hospital and said, I'm bringing my child in. He's allergic to peanuts. He's just had a peanut and he looks ghastly and this child um, is alert but has developed a widespread erythematous red rash and swollen lips and is making all sorts of funny noises when he breathes, including so stride off an inspiratory Monon sound and a polyphonic expiratory sound. Wheeze. So, write down what is the most likely diagnosis here? This isn't rocket science, is he? Is it? He's about to walk through the door of your emergency department. This is probably anaphylaxis, isn't it? It's just possible. He's choked on that peanut and he's got a foreign body, but this is really anaphylaxis and, um, your nurses do observations as he walks through the door and he's tachycardic, isn't he? He's probably hypotensive as well. But don't worry about looking up normal um, charts for that. He's a little bit poorly perfused, his respirations a bit long and he's apyrexia and his saturations are low as well. So, if we're doing that assessment, you, you are recognizing this is a sick child. I hope so of anaphylaxis. You can get sick very, very quickly. Indeed. Either because of upper airway collapse because of edema, because of bronchus spasm and, or because of circulatory collapse. And you can have circulatory collapse in about 10% of patients with none of the other signs at all. They get sick very, very quickly. Indeed. So you're going to call for help, aren't you our assessment? A? We're not sure this child's airway is entirely patent. Are we? He's stridulous and his lips are swollen. B he's tachycardic. His SATS are low, he's wheezing. And when you listen, widespread wheeze c cardiovascular, he's tachycardic, his BP is low. His cap refills a bit low. His pulse is actually bounding but it's hard and fast and he's got this widespread rash. So, what are you going to do? What is your treatment of this child? Can you write down? Do you know you can do doses? Great if not just know what, what drug to call for, to call for anaphylaxis. You're calling for adrenaline. Yeah. And your adrenaline is im, that is your treatment that will treat all the three areas, the upper airway, the lung circulatory, failing that you can nebulize it and you might want to nebulize it as well if your rear is stride or is the main problem, but you just whack it in IM, not IV, I've seen a child killed by it being given, Ivim. You give Im and ideally your hospital should have boxes set up where you don't have to actually calculate the dose. They're just set up with prefilled syringes. But failing that the dose is 10 micrograms per kilogram. Im adrenaline try and remove any trigger if it's there, give oxygen. If there's significant circulatory collapse, you might want to pour in fluid as well. But usually adrenaline just tightens everything up and gets you out of that situation. Um, you might want to give a salbutamol as well and at some point you're going to give Pyon and steroids, but those aren't the lifesaving things. It's, the adrenaline is a lifesaving thing. There's not many many situations in pediatrics, you just need to know what to do and not have time to look it up. And this is one of them, these situations I'm talking through are those. And there's good, nice guidance on it. Let's do one more. We've done ABC. How do we assess? D let's practice on this poor patient. This patient has been sitting in your waiting room, snotty coughing and very high fever at home. That's where dad and suddenly a three days worth, let's say suddenly the patient has gone stiff, head is back and they are jerking. He's having what looks like a tonic clonic seizure. First of all, I want you to write down what is the most likely diagnosis here and your potential other diagnosis and make it appropriate for your own work and your own country. Ok? We'll go through that in a minute. Then I want you to think we know how to assay ABC. Now, don't we? How do you assess d in this emergency setting? What are the key components of it? Can you write that down as well? Really commit yourself on paper? What are you doing? Ok. And finally, what is your immediate management here? Are you worried? Are you going to call for help? What, what treatment are you going to call for? Ok. Let's go through each of those things in turn. So assessing the c of sing child, we can skip through airway breathing and circulation fairly quickly airway, you need to know this child isn't, is safe. And if they vomit, they're not going to, um, asphyxiate on their vomit. And if there's lots of secretions, you need to be able to remove them either with suction or just pulling them away. Breathing really hard to assess, isn't it in the convulsing child when everything is juddering? But it's reasonable to put on oxygen measure. Sats and have a quick listen. Cardiovascular again is pretty difficult to assess in a child who's having a seizure, but you can certainly have her do a cap refill and a heart rate. But then you're on to D Glasgow coma scale is very similar to adults as you're aware. But in the emergency situation, let's use AV who are they alert? This child's not? Are they responding to voice? This child's not? Are they responding to pain? This child's not? And that correlates with GS on a scale about eight, doesn't it about when you lose your gag reflex flex? Or are they unresponsive? What's their pupillary size and reaction? This child has midsized pupils equal on both sides. What's their posture and focal signs? This looks like a generalized seizure and they are seizing intermittently, clonic and tonic neck stiffness. You can't assess if a child is having a seizure, but we can assess their sugar, can't we? And that's particularly important in all of those who live in malaria prone zones where this is much more likely to be malaria than other things. That's how you assess the comfortable with that. The emergency s to's go back to this child. What's it most likely going to be in my country? It's almost certainly a febrile convulsion. So febrile convulsions is an inappropriate response to temperature. Usually, viruses usually at the onset of the virus actually associated with release of um viral load and inflammatory markers right at the onset between Children, between the age of one and six. Outside those times, you're suspicious. It's something else. And it's usually in Children with a family history, they're very common. About one in 30 to 40 Children in our country have them. If you have them, you've got a one in three chance of having more and they're not generally associated with epilepsy. As long as there's no family history of epilepsy, the child is developing normally and birth history is normal. But of course, there could be other differentials here because of there. And in areas such as Sudan, certainly malaria would be very high on your list of differentials. As would other infections in our country, meningitis, encephalitis, um parasites, abscess, nonaccidental injury, brain tumor, or first presentation or peak presentation of epilepsy. And I know certainly in Sudan you have a much higher prevalence of epilepsy than we do in our country for all sorts of reasons. But whatever the diagnosis your first management is the same, isn't it? It's that assessment at giving oxygen calling for help putting into the recovery position and then just keeping really calm and watching the clock, this child's seizure is almost certainly going to settle before five minutes. If it hasn't, then at five minutes you give your first treatment and your first treatment is a benzodiazepine midazolam is as effective and as any and probably the safest and is a cheap medicine and can be given Buckley. And it's one of those doses, it's really helpful to know naught 0.5 mg per kilogram can be given Buckley and usually works failing that diazePAM can be used, but it's a dirtier drug more likely to give you um um poor respiratory effort or LORazepam can be given IV using all our seizing algorithms, you would then give another dose of benzodiazepine if the child was still fitting 10 minutes later. So that's 15 minutes. That's given you a lot of time to look up your guidance, um assess the child properly, bring in help as well. So just knowing that early assessment will give you a lot of support and help you to treat this child properly and give them the right dose of benzodiazepine, not overdose them. There's very good guidance for all of that. This is the side I've just added given to given the audience I'm speaking to. There might be other stuff you need to do here in that 15 minutes. You might be so suspicious. This is a bacterial infection, you'll want to actually get IV access. Um Make sure you get your sugar, especially if you're worried about this being malaria and blood cultures and the gas and give antibiotics. So just to remind you if sugar is low, you can treat with dextrose 10% dextrose two mils per kilogram, broad spectrum antibiotics, antimalarial. Um We all follow very similar algorithms for the management of seizures beyond 10 minutes. But the resuscitation Council UK A is certainly a good resource if you don't have one of your own. So that's quite a whiz through emergencies. It's very much focusing on your assessment. Hanging on to your ability to be able to observe, recognize a sick child. Use ABC D as A as a sort of a very important scaffolding to organize your care round. And just to say, although this is a talk for a resource rich country, we have done very few investigations and the treatments we've used have all been pretty cheap actually. But what we've done is use them in the correct doses and the correct amounts with authority knowing that they are safe and well trialed in Children rather than adults. That this is a picture from where I work the top of level 12 pediatrics. It always looks a bit misty and wet like that, take home messages, Children are different, but they're not that different. It's all about recognizing a sick child before it's too late. Get help in early, assess and manage ABC DE use your observation. If you're gonna do investigations, think them out carefully. We don't do very many investigations. That is huge life saving potential if you do the right thing. And I hope you've got the feel of pediatrics is a wonderful career. Thank you. I'll try and answer questions if I can. I hope that's been helpful. Thank you very much. Wow. Is that what you're wanting? Perfect. I think from the chat, I think everyone is for some reason, I can't see the chat. I'm not getting anything new. If you hit refresh. Is it coming up? Oh, where's refresh? If you just go into your uh URL bar and just hit return at the end of the RL? I think someone did say who asked a question. Oh yeah, I've got something there. Did you keep an eye on questions? I'm so sorry if I have a few questions you may have answered there, you may have answered it. Um If I ask how much adrenaline do you give? What for you were in? You were talking about? Oh, I'm trying to see. So Croup it's four mils per kilogram of one in 1000 nebulized to a maximum of five mils. So once you're over 10 kg, you're pretty much on the maximum. It's five mils one in 10,000. Yeah, for um for anaphylaxis, it's anaphylaxis, lots of guidance. Um But again, it's 10 micrograms per kilogram. Im that's what you're giving. Perfect. We at 0.1 mils per kilo of one in 1000. Ok, perfect. Does anyone else have any questions if you want to pop them in the chat? I am actually going to let you know that I'm hoping on the, I think it's the fifth of October. We actually have somebody coming along to give us a pediatric fluid management course. Ok. We have, we were talking about it and it was like, oh, I think I might have someone because you were saying about the importance of it. So that, that's great. Yeah, it's just one of those things you, you need to do properly and if it's done well, it really is life saving and if it's done badly you have potential to damage. Actually the same with airway management in Children. Yeah. Oh, so Yvonne says it was for the anaphylactic shock. She answered it along with the Yep. Perfect. Yeah. So any other questions? Anyone everyone happy if you could fill out the feedback form, I'll pass that on to Katherine. I'm really happy to give further talks, but I'm a bit stuck for what's useful for you. Given my background as a general pediatrician. So if you put things in the topics, I'm really happy to create talks about what might be useful. I'm very much a generalist though. My area of expertise is bladder and renal, but I do a lot of acute pediatrics. So we do a, a feedback form. There is a question that says, what else would you like to learn on this topic? So once you've got that the feedback will be sent to you via email, Sarah. Once you've got that, then you can have a look to see what you'd like to do and maybe we can get Catherine back again to do one of the talks that you have asked for in the feedback. OK. Everyone. Oh, hang on. What type of fluid is used for resuscitation. So that, that's a really good question. We are still using normal saline actually 0.9% normal saline. It's you're probably aware of all the fluid studies and controversies. Ideally, you'd use plasma light or Harmans, but we are still using normal saline and that's certainly the cheapest. So use what you've got as long as it's isotonic and and have another one which fluids to use as maintenance fluids. So again, in, in my hospital, in our country, we're still using naught 0.9% normal saline with 5% dextrose as isotonic. And we would usually add potassium 10 millimoles to 500 mils. But increasingly we're beginning to use plasma light and Hartmans more. But again, use, use kind of what you've got. There's lots of guidance out there and food is something I'd really urge you have just a really nice little bit in your notebook or phone or something that you can refer to to make sure you're doing it correctly. Perfect. Brilliant. Well, I think that's it. We've got no more questions. Well done, everyone. A very good luck with everything you're doing. Yes. Thank you very much and thank you everyone for joining. Thank you, take care. Thank you. Bye bye.