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Sorry that it's been uh I'm really, really sorry, it's been a hassle for you. Um Today, I'm just going to have to take off because now come up with this path. All right, let me get rid of that. Good. So hopefully you can see my slides. And so money is Michael. I'm a pediatric emergency consultant in Bristol and I was very much in Imperial territory for many years before that, which started giving these lectures. I am, I'm sorry that we had to switch from, from M S teams. It seems to have identified me some sort of terrorist to the, to the imperial um side of things which I'm used to having, having been refused access to, to America recently because I've been to Iraq with MSF in the past. So teams doesn't like me, but hopefully Zoom will and this will go smoothly over the next sort of hour and a half, two hours. We're going to go through some pediatric emergencies and topics and some just acute pediatrics and feel free to jump in with any questions at any time. Um And also if you've already covered this another lectures and you like Michael just shut up, then, then, then that's fine. We can, we, we, we can move on. Okay. So just tell me what's useful for you, feel free to ask any questions related to this or other stuff as we can. So first and foremost, I'm sure you get lots of generic teaching on, on actually how to approach your SBA is just a couple of things from my perspective are to just consider. So the main thing is when you are looking at SBA or, or MCQ, when you're looking at the thing, someone has written that and someone has put in the words into that MCQ for a reason, right? Like they've done that SBA for a reason and they're not just really nearly kind of put in a case study, they've put in like they've included information and it has to be relevant to why you're going to answer the question in that way. So just I'm sure, you know, already and you get it by passing recognition but actually analyze what the SBA is asking you and just think about why they put in there like the little bits that go along with it. So if they put in that they are, you know, that they are pale, um that presumably means they're anemic, they're, they're pale and jaundiced that they're probably, they've got the humility can email, for example, like if they look toxic, they're normally they normally got epiglottitis, you know. So what words are in there that, that they wouldn't have other boys put in to make you think about what the diagnosis because mom's got a new boyfriend that's normally, that is normally a child, child protection kind of issue, that kind of stuff. And part of that is what is, what, what is actually asking you at the end. So, this is Scott who's a five year old and presents with an acute exacerbation of it. That's in there most quotation, he's wheezing bilaterally and he's working hard. And if that's 90% of their, what is the most appropriate initial management? You do? IV savvy, small inhale savvy, small face mask, oxygen, magnesium, self asynchronous link. And before we get started, uh we'll just talk about the answer these questions, but I would put some face mask oxygen on him first, we're going in A B C D approach and two most acute stuff and he's clearly desaturating. And so he probably needs some face mask oxygen. And first, which is a little bit different to saying the exact same case and what is the most appropriate management to relieve his symptoms? For example, because the oxygen is not going to relieve his symptoms, but inhales had these monets. So just worth always just thinking, what are they actually asking me? And am I getting I'm getting the right information from this uh from this question, you can normally eliminate at least two answers at the beginning to say that these are, these are probably ridiculous. Even if they all look vaguely sensible when you first look at them with a little bit of more, kind of, more reading of it. You can normally get rid of at least two and then you're down to one in three chance of getting answer. Right. Even if you're not sure. So, Tommy's three weeks old and I actually can't see when sliced, like, still got the things. I'm going to just do this. Um He's uh he's her mother. I said you can get him circumcised but refuses to tell father what's the most pro protection? Do you want to call social services and ask for marriage counseling? Do you want to perform, perform the circumcision? Urgently? His mom's consented, explain to mom that you need to wait to perform the circumcision until you have consent from both parents. Uh Explore why mom doesn't want the father to know and suggest that the decisions are made best as a team perform DNA testing to confirm the mother and the father's identity. So I think we can think that a and er probably definitely not appropriate. And in this case. So even if you think, oh God, I'm not sure I do in this situation and this is a little bit of an extreme one. Um But you can see then that we're kind of like narrowing it down probably to B C and D and then the word urgently that's got to be put in there and be because that's 23 or percent because you could perform circumcision as mum is consented. Technically, because you definitely need one person to consent to uh uh to, to a medical procedure. So when they're, when they're apparent, but you need to do it actually, is this emergent circumcision? Probably not. So that's, that's why that word has been put in there to kind of put you off there to, to make that less obvious that that's not the right answer, you know what I mean? And then in this one, you'd obviously take the high road and explore mom, just want fathers note and it suggests these decisions are best made. The team's not be your first kind of your, your first kind of employee there. But you can, you can start narrowing that down from 5 to 3 to two. And then even if you're not sure you can, you can normally pick ones. Um So that's just a very quick, just a very quick thought on actually kind of like the, the, the technique and, and I'm just gonna jump in with some more acute questions if that's OK. Um What I'm going to try to do is make them relatively clinical because you can get all of the answers from, you know, biochemical and, you know, kind of the theoretical knowledge a for books and beef question banks. And so this is gonna be more, more clinical stuff to give you more chance to ask clinical question because that's kind of what the, you maybe don't have as much access to when you're deep in revision mode. And we're going to do one question, then a bit of a discussion about the topic and then some more questions if that's okay. So, healthy, 10 month old boy has a two day history of coryza and fever up to 38 degrees. He's a barking cough and over the last few hours since developed inspiratory stridor, he's mild to moderate respiratory stress and option saturations in 99%. Today, he's not drooling at his temperature is 38 degrees. 32. What is the most appropriate initial management? So do you want to give him an adrenaline nebulizer? Do you want to give him 10 puffs of inhaled Selby small and observe the response. You want to give him facial oxygen and review after 20 minutes. You want to give him IV hydrocortisone and take a blood culture and commenced ivacaftor except we want to give or dexamethasone and observe into respiratory distress. Settles. I can't see the chat, I'm afraid. But do you want to pop in some, pop in some answers? And then, and if you're happy to give me a summary of what people are thinking, we've got a vote for E one bite. Yeah. Is that the official spokesperson of the of the group? Anyone else want to confirm or refute? E Yeah. Okay. Six point yeah. Most people saying you? Great. Okay, cool. That sounds about right to me. And that's one of those slight heart sing questions, isn't there? It's like I've seen the web barking cough. So I know that this is probably group. And then you're like, well, where's the answer? Croup? And you're like, oh God, you actually want to know what to do with it. So it's some, some of these, you'll get two layer questions inquest some of the clinical and sometimes feel like that a little bit to me. And so this one, you're absolutely right. So you made presumably correct diagnosis of croup and then you're gonna give some more dexamethasone and observe until the respiratory distress settles. So, just to think about airway compromise in general, um so we've identified that this is an upper airway thing because they've got Strider, right? And remember the Stridor is inspiratory and wheezes experience because Strider has an eye and we've had any, right? So inspiratory and expiratory and it's just interesting to think where those noise is coming from. So just very quickly, if you have Stridor, as you can see the middle on there, it's from your larynx to your carina. That's where true Stridor is. And does anyone know, does anyone know the proper name of Croup? Like long name of Croup? Want to pop it out there? There you go. There's someone, someone said something in the charge come see what it is, what sound said laryngotracheal, bronchitis, well done. So good effort. So, laryngotracheal bronchitis, that is basically the definition of strider, right? You've got a noise coming from your larynx, your trachea and then the very top of your bronchitis. And so that's why, that's why croup is the absolute classic tribulus kind of presentation. And below the coronet looking bronchospasm and you're getting wheezed as you're experiencing kind of science and then above the lecture, actually getting stare, it'll startle is like a snoring noise. So kind of like if you imagine someone with decreased consciousness or who's got very severe tonsillitis, for example, they had, they'd be an example of someone who has um has a startle, it's kind of a kind of noise. I mean things that we're thinking of in these kind of areas that you're hearing these kind of noise or you think it's coming localizing from this kind of uh this position of the airway. So tonsillitis, retropharyngeal abscess, decreased consciousness will be your kind of stertorous Snorri kind of noise kind of in this area, looking at classically anaphylaxis, croup, epiglottitis, which come into in a second foreign body. And then if we're really going kind of like a left field, then then diptheria or other kind of upper respiratory tract and severe upper respiratory tract infection. And and then laryngomalacia, which is obviously at your vocal cords, which is very common presentation, small babies who present normally asymptomatically with kind of strider, particularly they're upset and we'll throw in subglottic stenosis there as well. And in the question, what normally happened to them before? They, they've got a diagnosis, subglottic stenosis. Do you think it's going to be in the question? It's some says that they've got some plastic spaces. So it's classically that they've been intubated before. So they've, they've been an X premature baby and they've been intubated and then they've got kind of a narrowing after that. It goes below the, below the focal cause. And then obviously, we're looking at things in the, in, in, in weeds, like asthma and viral and you squeeze and then down in, that's in the kind of the bronch I and then right down in the lungs were looking at bronchiolitis and pneumonias were like down in the actual LVO lie and bronchial level. So it's just a very quick overview of what noises were hearing and where they're coming from in the airway. And sometimes it's just helpful to kind of think anatomically. So like if you've got a child with respiratory distress, like even if they're not told you what noises, right? It can only be from the pharynx, from the larynx, from the trachea for the bronch i or deep in the lungs. So it can only be one of those places. Let's just think about where it is and what could cause it. So for upper airway badness just can you give me some, some options of what you think? So, if someone comes in in significant spirit, like have got decent respiratory distress from and when they've got Stridor and there may be, option levels are a little bit compromised, just joined throughout some things in the chat that you might be thinking you want to do, try to calm the child, that sounds very sensible. Um So that's, that's going to be your absolute number one. And it's a step away from the child and try to try to avoid any stressful or painful interventions. And that's quite classically, that's quite, quite a common question to come up because it shows that you've actually been on the wards and that you've actually kind of thought about clinically how, what you do about this and say everyone wants to jump in with someone with some active treatment, but actually stepping away from a child who's got severe, uh We compromise is normally a good idea and we actually want to give them some oxygen if they're, if they're an extremist and if they're saturations are low, so it needs and it's tolerated and you normally want to get the lead in the room and generally, that's gonna be your seniors clearly, but also ent and anesthetics, people that you might need in the room to manage a very different difficult airway. Um then your options to actually treat it are to reduce the information. So in extremists, you're going to use adrenaline nebulizers first, that's going to be your first go to, for a child with Strider who is unwell. So you're gonna give adrenaline and that's the same, whether it's anaphylaxis or whether it's a croup or whether it's ethical Otitis or whatever. The first thing that's going to act on your railway is gonna be adrenaline. So, not 0.4 miles per kilo, up to a total of five mils is the dose. You probably don't know the actual dose itself, but just, but that's your first line and then dexamethasone. And as we did this question, so it works in about, it takes about four hours to start working actually, and then continues working for about 24 hours. So it's a little bit of a slower burn and then the adrenaline. But if they're not sort of sick, it's significantly compromised and they can wait for that to take effect as in that case, we just did and then, then dexamethasone is gonna be your first line for most people if they can't wait that long because they're desaturating. Well, they're working very hard. Then that's going to be when you trigger the adrenaline nebulizers during speaking, be Disney's a little bit of an add on for us and, and you know, most guidelines, it's kind of like a third, a third option. But in most questions, you're going to come across, it's going to be dexter, it's gonna be adrenaline. And then obviously, if there's an underlying cause if you think this is epic lot itis then you're gonna think so. Sorry, you're gonna think you're going to want to treat it with antibiotics. And for example, if they've got an anaphylaxis, do they need to have a fluid bolus? Um And do they need sort of further management from a perspective, classic kind of medical school questions about croup versus ethical crisis, as you'll know, ethical crisis is extremely rare and these days and that's because most people are vaccinated against him. But there's sort of decent communities for those who aren't. And for the point of your, for the point of your M C Q s and just thinking about you think about paying some people lots of times people think about hepatitis. If you look at the two ends of the spectrum, croup is a viral illness is normally caused by parainfluenza, but it can be many other viruses. You get a harsh strider with a barking cough and that's the one that's one that always comes up in the, in the questions. They're normally clinically well, right there, normally relatively young child and clinically well, and that's just the the vision of the child that you have to have in your mind for hepatitis. They are the other end of the spectrum, they are bacterial. So they are septic, they look absolutely rubbish, they are normally toxic and they're drooling. So the two words you're looking for are toxic and drooling. And in a, in a vignette that's talking about epiglottitis and and they are, they are bacterial infection that they need IV antibiotics and it's normally sort of a slightly more insidious onset and normally there's no real cough with it. So, the barking cough you think? Oh, that's upper airway. That could be either barking cough is croup, rep eclecticism, which doesn't have much of a cough in the middle. You've got bacteria tracking itis, I never really see questions come up about this if I'm honest. But, and the way to think about that is that it's kind of just worse than croup somewhere between them. But you've got signs of bacterial sepsis and a very unwell child who's not drooling a toxic but is, has a barking cough in his unwell and 97 time, it's gonna be creep. But just to be aware that that's kind of differences on the spectrum, it's like a goldilocks coop is, you know, just two little epiglottitis is too much and bacteria tuberculosis is just right in those questions. That's a picture of a child with croup. Just get that in your head. They are viral. They are normally quite well, but your track ISIS is nasty. That's what it looks like inside. You can imagine. You'd be pretty unwell and that's what you're tricky look like, both from a respiratory perspective and from a back to your perspective and that's what epical it isis looks like. Super angry, super unwell child. Very, very quiet, strider, difficult to kind of difficult to manage. And that's when you're doing your step away, get the people you need, get some adrenaline if you can use it quite often. Their try putting as well. Okay. All right. So that's just sort of covering very quickly up some, some common upper respiratory stuff. Let's just think about a couple more questions. So, Lisa is three years old and presents with a coffin striver. She appears unwell and she's drawing, she has subcostal substernal recessions and trickle tug. What's the most appropriate initial management? So would you like to obtain IV access and give an IV cefTRIAXone, examine the throat to confirm the diagnosis. Keep the child calm and call for anesthetic in the anti support. I am adrenaline and wafting oxygen to keep the child calm, nebulize be desonide and facial oxygen. So, Marina I'll take that question in two seconds once we've got the answer to this one. Yeah, of course, we're saying lots of C's and that sounds, that sounds right given what we just talked about, right? And so initial management here is again, keep child calm and, and called for an aesthetic in the anti support. But more definitive management is going to be giving adrenaline in the first instance, probably intubating them and getting and getting IVF tracks and, but clearly, that's going to make things worse in the, in the, in the acute setting. And so completely agree that looks very sensible. So grunting very quickly, grunting you have come across and you is basically giving yourself CPAP. So it's from a closed lotus. So you're basically making you're forcing air out against a closed lotus. Um So you're closing your vocal cords and then going to kind of force air out and please turn your mics off if you are doing this, but just try that yourself for a second to just try to try to grunt for a second and just feel the burn in your chest and you literally give yourself CPAP and, and again, people do this in the room and everyone really embarrassed about it. But at least I hope that the camera off like you can, you can do this and just your house makes me think you would, but it just really try to breathe out against resistance and you just feel a bit of burning your lungs and that's giving yourself think about. So that's where granting comes from it. It's not a sign of upper respiratory problems. It's a sign of lower spiritual problems, but you make the noise from your lyrics. That makes sense. Cool. OK. Lucy's three years old and presents with strider and a spreading rash after returning from a played rate as a friend's house, she's given I'm adrenaline by the ambulance to present to 80 10 minutes later, she's allowed strider, swollen lips and respiratory stress. Her sats 92% are there and she's wheezing. What is the next most appropriate management step to relief symptoms. So you want to give 15 m, votive ionel rebreathe bag. Give I am adrenaline, nebulize adrenaline, nebulize salbutamol or obtain IV access and divide hydroxyl second. Okay. Few more of its. Put them popping up with. I've got one vote. I've got one vote of be anyone want to disagree with that. I disagree with it. Now, if you're game too. Okay. All right. I agree. And so a lot of fewer votes for that one than the one for the last one. And so this chart, the way to relieve symptoms of upper airway compromise or any compromise in uh Zanaflex is, is to give adrenaline in one way or another. And it's just a kind of flag, I guess that whilst we give nebulized adrenaline for most of the pure respiratory problems and where you actually, where it's just your airway that's kind of compromised. And you can think of this as a systemic kind of compromise because they've got anaphylactic shock. Right. So that's, that, that's what an flat flexes is. So you give, I am adrenaline to make it a little bit more system, like systemic, to get it in very, very easily. So it's always I am adrenaline that you give first and then you can repeat that dose and if the symptoms have improved. So most like nearly all of the new anaphylaxis pathway is give adrenaline in some, in some form and don't worry too much about most other stuff. Giving 02 is probably a good idea and it was obviously a good idea in your A B C D. It's not going to relieve her symptoms. And actually, yes, that's a 92%. So, you know, she's very sick but, you know, you could, they put 92% in the question to say you probably don't need to oxygen. Absolute, your first priority here. But getting some address and more adrenaline into her is because that's what's going to solve the problem. Okay. So basically most of it in and flex this adrenaline and then if you're still struggling, then you need to cannulate and start an adrenaline infusion. That's the treatment of renflexis. We know that steroids work very slowly. So they're not part of our acute algorithm anymore and chlorphenamine as well and it's going to work slowly. So you get your adrenaline in control the allergy and then take it from there. Ok. Hkifa is four weeks old. She's brought to a any with noisy and spiritually breathing, which has been more prominent over the last few weeks. She appears well on examination but has some inspiratory stridor and it's more obvious when she cries, she's gaining weight and she's a fibril. What's the most likely diagnosis? So, does she have bronchiolitis? Does she have foreign body aspiration? Laurinda, Malaysia, subglottic stenosis or tracheoesophageal fistula? Good. Okay. We've got some confidence season that so well done. So this is classic history of living in Malaysia. Right. And living in Malaysia is that you've got a floppy larynx and where you're the proportions of your, the proportions of the back of your airway and your tongue and all of your kind of proportions are a little bit different when you're a small baby compared to when you're a bit older. So you have a bit of a floppy that you have an epiglottis, which just kind of like sits over the top of it. And so it just gives you a kind of a resting strider, which is more kind of obvious when you're, when you're screaming the place down and sometimes when you're feeling and it's normally kind of quite squeaky. They get a little bit of a spiritually stressed with it, but not much and normally peaks to about 6 to 8 months, something like that. And then we'll go away by itself. It's not something that needs intervention unless they're struggling to gain weight. So again, if this is, this is the question here is that she is gaining weight and she's a febrile. So why has that been said? It's because this is a benign conditions, right? And if the same thing is in a jaundice history, for example, it's going to be sure there's or something like that, this is saying this is a physiological thing if she's gaining weight and she's a fibril, most things that are in that in different kind of areas of your kind of SBS are gonna be physiological variants most of the time or anatomical variants that are not hugely pathological. So it's just kind of a bit of a flag for that. And bronchitis, obviously a lower respiratory tract stuff. Very unusual to swallow something in a four week old. Like they're not, they're not playing with LEGO. Hopefully at that age, no history that she's been incubated or that she's had kind of severe and respiratory severe strider from birth for subglottic stenosis, tracheoesophageal fistula is where you've got a hole between your trickier in your esophagus. And normally you're kind of aspirating and having quite significant respiratory signs with that. Probably not getting much weight because you're gonna have some chronic infections and a lot of difficulty with your feeling. Okay. Does that sort of make sense on that? That's, that's we're gonna whizz through sort of topics, but it's just to kind of like have a flavor of topics whilst answering sort of some, some questions. I'm thinking about some technique as we go along a stop moments before we continue. Is this, is this useful for you? Is this what you'd like to continue doing? Be, are there any questions on this and, and see uh the things that we're going to cover are going to be fluid management card, um, congenital heart disease and collapse, basically lower, lower spiritual track stuff, seizures and rashes. I think probably the things we're going to come up with a similar think if anyone says we've already done those, I don't care about those and that's also fine. But if you're happy to continue as well, and how would the management differ if she wasn't gaining weight? Good question. And so it's an indication to do something more, right. So, like if there's a red flag in the history, it's an indication that it's not going to be a simple, reassuring home or a simple. This is, this is fine, don't do anything. It's going to be a referral to ent um if they're not gaining weight and so they're gonna need to scope and, and in the initial setting and do you potentially get some anti reflux medication as well? So they gave you a good history, there's some reflux in there with the ring in Malaysia. You start with an M result and that would be a good initial thing to do to kind of reduce the inflammation a little bit and, and then definitive management ent will, will potentially take them to theater and just snip some of their floppy are way off. So to give them their hair drips around the around the larynx. Okay. Cool. All right. I'm aware that it's just my voice on here. And so I am sorry and if I if that's painful for you, but please do jump in at any point and ask any questions verbally or tell me that you want to do something different verbally. Right. Question too. And see, Nanna is one year old and presents with abdominal pain and vomiting. You finasteride up for maintenance foods for her and she weighs 12 kg, which food regime would be the most appropriate. Okay. Go with this. So 500 mils of normal saline followed by 500 mils of 10% dextrose over 24 hours, 1100 mils of normal saline, over 24 hours, 1100 mils of. So Saline plus dextrose over 24 hours, 1200 mils of N A C L over 24 hours or 1200 mils of N A C L plus 5% Dextrose over 24 hours. What do you think you've got one break person tip at your head above the parapet? Well done, Jack, we're done. Emmanuel any other office other than see, well done. Alright. Does either Jack or a manual or anyone else who also agrees with the answer want to want to give us a quick, very quick tell us how you, how you want to know why? I think that's right. Yeah, I have to do so with the prescriptions and Children. Your 1st 10 kg of 100 mil leases um per kilo. Your next is 50. So for the next 10 kg is 50 mils per kilo. Uh and then the remainder is 20 mils per kilo and that's not taking into consideration any fluid you use resuscitation and that's just for maintenance, which is overall and you can use both sitting quad and dextrose and then uh perfect. Absolutely. And I hope everyone's happy with that as well. So a really good explanation. So this cause a lot of controversy in a lot of controversy. Medical anyway where it's like, why do I have to remember this? But it is a, it is something that can come up. It's a little bit frustrating if it does basically you have to. So why has extra is actually food? Exactly a good question. And so basically in adults and it's a long time since I've done adults but, and you can correct me of that wrong. And over 24 hours, you quite often do one salt and two sugar. So one sort of N A C L has got 150 millimoles of sodium chloride in it and that's the amount that you needed that that day. But then you don't need any more electrolytes. So you get two bags of 5% dextrose over 24 hours if you're not eating anything. So 3 m over 24 hours, 88 hours each. The point is that as an adult, I don't know when you last ate, but I, I haven't had too much in the last eight hours and I'm okay. So we can go eight hours without having any sugar and that's fine. But if you're a child, if you imagine a baby sort of having to eat, like you don't babies don't go eight hours without eating anything. So they have smaller supplies of Glycogen, small, therefore, supplies and glucose. And so they need constant glucose to kind of top that up to give them to give them energy and they'll become hyper, blessing it a lot easier. Um, so if they would feed every 2 to 3 hours, for example, and you're giving me to the flu is you just need to give Dextrose in everything that you give over 24 hours. Um It doesn't matter, what else is it actually? So like the dextrose is the non negotiable part and obviously want to give electrolytes. So, so provide an open 9% is fine, harmond is fine, uh plasmalyte is fine. So you want to electrolytes plus dextrose obviously, and you want to continuously over 24 hours and just very quickly for the chat, given that. Okay. Well, let's, let's, let's let's let's talk about fluid in general and then let's just do some more, more, more options on it. And so your three options for pediatric fluids and just try to make this sort of relatively straightforward. You have maintenance fluid as we say they have electorates and they have extras in for those reasons. Exactly. Is um as you kindly pointed out, I'm not sure if that was Jack or Emmanuel, but thank you very much for, for, for whoever did it. It's 100 mils per kilo per day for the 1st 10 kg. And cumulatively, you have to add on 50 mils per kilo for every of the next 10 kg. So 10 to 20 kg and then 20 mils per kilo per day for everyone. After that, we normally cap it at two liters. So you don't normally go over. So you got like a 60 kg child you have captured at two liters. So I think at 50 kg it caps out of that and then 55 will be the 10, 2 liters, 70 kg will be two liters as well if they're under 16. And so very quickly on that basis, if they were, if they were 22 kg and you want to venture a guess at what I guess a calculation of what they would need in a day if they were 22 kg. Yeah. Very good. It's always given to people agree immediately and yeah, 1540. So 1000 for the, for the first part. So there's three black lines there, 1000 for the first part. So 10 times 100 500 for the second part, 10 times 50. And then you've got two left over and so you're gonna do two times 20 which is 40. So 1000 plus 500 plus 41,540. Okay. All right, good. I've done, I've forgotten. I put that in and that's saying exactly the same thing with a very slightly different. So bonus fluids bonus fluid. We're going to give 10 mils per kilo and as a bonus in case that's the resuscitation fluid and that's where you don't have the dextrose because what you don't want if you got a stress response and you're kind of your, your cortisol's really high and you're kind of like telling your body to go into overdrive is a shed load of glucose being given to you as a bonus if your sugars already quite high. And so it's just 10 mils per kilo of an electrolyte. So N A C L or plasmalyte would be a classic ones, heartburns if you really want to and more ringle acting and that's in most situations and you can be more cautious in a couple of situations. So trauma, it would know why you want to be a bit more cautious in trauma. No. So it's generally, yes, it's not actually cerebral edema. So you're, you're absolutely right to think about uh cerebral edema in DKA. And that's the reason in DKA that were a little bit more cautious. Sometimes all the more modern guidelines are kind of going a little bit more liberal on that and even trauma, your first clot is your deepest. And so hopefully that that's what everyone said. But you make a clock with your best clotting factors. And if you give a shed load of fluid and you birth that clot and then all your best clotting factors have gone and you're going to bleed out through it. So we're a bit more cautious and trauma and quite often you get blood instead of fluid and fluid overload. Clearly, we don't want to give too much extra fluid or heart failure. And then sorry, and then D K will be the other one where you worry about cerebral edema and just to kind of vocalize why that is and just make you remember that that's the complication. So if you get a D K A case who's confused or has a headache or anything, you've always got to have cerebral edema in your head and there's a complication. The reason is that you've had loads of glucose in your bloodstream for quite a while probably and clearly, what you don't want to do is suck a load of water out of your brain. And to, to kind of like to, to dilute that bad glucose, that sort. So what you do is you make a load of other osmoles in your break or in that kind of in that area that says, right. Well, I'm going to balance out the sugar that's in the blood stream. And then if you take all the sugar out very quickly and we'll dilute the sugar very quickly, then those, those molds are still there in the, in, in, in the kind of in this, in this room. So they will take water out of the circulation because now that concentrations drop quite quickly and it'll come over and then you get cerebral edema. So I find I understanding more when I, I remember things better when I know kind of some of the first principles behind it. That's why, that's why sometimes it's worth kind of just, just knowing that I think. Um but that is your big complication from D K. Um And then the only other real kind of situation that comes up with dehydration corrections and this is something which I'm just going to say because we, I always get a lot of questions about this, but it's something which you don't really need to know in too much detail. But dehydration corrections are usually done slowly so done over 24 hours. And just in answer to the question from, from gazelle there and flu bones would normally be over about 20 minutes like that. If you need it immediately, then you literally just get a syringe and you just, just, just put it through. So like it can be immediate and we have some Belmont rapid infuses as well, which you give up to, I think a leader in a minute. But so you can just pop it through. But if you're gonna do it in a sort of urgent situation but not a restarted, like not uh they're collapsing right now. Situation in over 20 minutes is fine. So dehydration usually over 24 hours and it's maintenance fluids plus the percentage they're dehydrated. So the way to think of this is that most of your body is water and then you have to estimate the percentage loss. So for the sake of this, I'm just going to do this the first principles for one second. And is that one key 1 kg way? So 1000 mills ways a kilogram and pretend your body is 100% water. So if you want to find out what a 3% weight loss in the 20 kg charges, you do 20 kg, which is 2 20,000 miles of fluid, 1% of that is 200 mills and therefore 303% of that is 600 mils. And so that's what you'd add on to the maintenance that you've already done. So they're deficit there, fluid deficits from normal is 600 mils and once you've got them to normal, then the maintenance is just going to keep them out normal. Okay. So, dehydration fluids are saying you are not at the normal rate, you have had a deficit of fluids and we must make that up and it's nice to make it up slowly because we don't want to overload them. So in this case, this 20 kg child would need 600 mils to make that deficit, but they clearly still need to maintain that deficit afterwards. They need to maintain the normality. So that's where they get the maintenance foods on top. The, the way to calculate that without knowing why is 10 times the weight of times the percentage dehydration and that just works out to the same thing. Um So that's the formula. But the first principles is that 100 to be putting water and it used to work out the percentage weight loss, the percentage loss that you have. You can do that two ways and you can either estimate the percentage loss and you don't put it again. This is just kind of from first principles, but you start seeing signs of dehydration around 3%. You get sort of try lips dry mucous membranes, around 3% dehydrated. You then start getting tachycardic around 5% start losing your cat refill at 7.5% something like that and then start losing your BP at 10% dehydrated. So that's kind of the way to do it clinically. Obviously, the best way to do it is to be is to be weighed. And then so if you know that in 24 48 hours, you lost 500 rounds, then you need to have 500 mils onto their correction. So they do this in the example, they're either going to tell you what percentage they are dehydrated and or they're going to say how much weight they've lost over a very short period of time. I think you'd be unlikely to get this in the exam. But it's just because I always get asked about this, that I put this like this does that sort of make sense? Any questions on fluid management? Yeah. So if you know the weight lost, then you just pretend that. So the question is, so you calculate the percentage dehydration based off the weight loss. So if you know the weight loss, then you know how much, how much fluid they've lost cause you're saying that's all fluid. Um So um if you know the weight loss, then you already know that. So they lost 500 g. You give 500 mils, if you lost a kilo, then you give 1000 miles over 24 hours as extra and, but if you're kind of going to do it and as a as kind of a uh you know, an estimated percentage dehydration and then you can, you can do that by, by the clinical correlation, which is, which is, I think a really elegant thing that your body does, right? Like if you were to design a body here and say, right, you're going to have less water than you think you are at 3%. You'd say it's a bit worrying guys, let's hold on to all the excess water that we're losing. So let's not pass any urine, let's not have any wet tears, let's not have mucous membranes because we need to hold all this water in. I'm still going to perfuse everywhere. Then you're gonna say, well, we've done that, but at 5% dehydrated and we're going to still try to perfuse everywhere, but we're going to work harder to do it. So we're going to increase our heart rate because children's hearts were pretty, pretty pristine so they can, they can increase the heart rate quite easily and we're going to perfuse everywhere. So that's a 5%. Then you start saying it's 7.5% that we tried that, but we just can't perfuse everywhere like that's just not what we can do right now. So we're going to have to prioritize where we perfuse. So we're going to send blood to our brain and to our heart and to our central area. So we're gonna cap refills, going to go down and at 10% you've tried everything and it's just you struggled. I think that's what you got pressure jobs. Um fine. So question and for the weight in the equation, do you use the original weight pre weight loss or the way they are? Now, that's a cracking question. And so if you know that, so if you know their, their weight before, then you don't need to use the equation. All right, because you, you've got to wait and you just use the difference between them. So you have to use the weight now because what they're normally doing in PCT is they're coming in and they are, and they, they look 5% dehydrated and you've got to wait on them today. So you just use that weight that you've given just once and I agree that is 95% of their actual weight because they've lost 5%. But we have to estimate them cool. All right. So a couple of questions. So Maria is four years old and weighs 17 kg. She presents with a non blanching rash in a fear of 39 degrees. Her heart rate is 100 and 80 and a BP. 64. Over 40. What's the most appropriate initial fluid management? Okay. Do you want to give her that amount of fluid and over 24 hours you want to give 100 70 miles of 9.9% Saline Bolus to review response to give her 340 miles of Saline bullets and review response 340 miles of Saline and Dextrose and or 340 miles of Ringer's lactate. Can I have the shelf to beat? Do I hear anything else? Cool. Be sounds sensible to me? Right. So this is just to emphasize that in, in resuscitation fluids, it's 10 mils per kilo of electrolyte with no DEX race. Okay. So that's what you give in in there in a child who is acutely unwell, who's either tachycardic and here the blood pressures or to compromise. So the lowest your systolic BP should be in any, in any child is 70 realistically, if you're, unless you're neonate um fine. And it's just to emphasize that used to be 20 mils per kilo used to just give 20 mils per kilo in 20 mils per kilo aliquot until you give 20 then 40 and 60 and now we give 10 and it's just always 10. It's up with this Marco presents following two days of diarrhea and vomiting. He has dry lips and mucous membranes is tachycardic. It appears lethargic. He's not tolerating any or, or intake, you decide to admit him for IV fluids and estimate that he is. I can't read that behind the thing. What is it? The what percentage dehydrated officer? He is, I can put you on here. He's 5% dehydrated and he weighs 10 kg. What's the most appropriate fluid management to instigate? So you want to give a bolus of 2200 mills at 100 mills or you want to give 1000 mills 1050 mills or 1500 mils? I have a choice France. Okay. I hear any. Do you hear anything else? Okay. I would go with the and why do we think he anyone who agrees? You want to tell us? Okay, I'll tell you what, I'll tell you why. I agree. So you think he knows he's 5% dehydrated. He doesn't sound like he's, they haven't given you anything in the question to say that he is hypertensive or that he's grossly sort of like grossly grossly unwell. So he probably doesn't necessarily need the bolus here, but he needs to have rehydration fluids and it says you have, uh, you said to him for IV fluids. And so it's telling you what you need to do and, and then he is 5% dehydrated. So always Tenke those, that's 10,000 mills, 1% of that is going to be 100 mils. So 5% is 500 mils. So you got 500 mills that you need to add onto your maintenance and 10 kg is 1000 miles maintenance over a day. Okay. I think that makes sense. So, you've got the 10 times 100 which is your 1st 10 kg, which is your maintenance. That's 1000. And then you've got your 5% of 10 of 10 kg, which is 502 adults. Okay. All right. We're gonna move on any last questions on, on fluid management just because it's, it's, it's something which everyone gets really worried about in the days before your exams. Those are the only things you need to know is mainly about Mason's and Bolus. Um, the last thing I put in there, which I haven't put on the slide is that the Dextrose bolus is two mils per keto of 10% Dextrose. And that's probably only other, like actual flu bolus that you, that you may need to notice the hypoglycemic. And then that will be your greatest good question. So, the D K for your management is over 48 hours rather than 24 hours. Um It always used to be and I, my honest answer is I can't remember on the current guidelines. So that's probably something to look up. Um, I believe it is over 48 hours, but I would just check that on there. There's a, there's a really good guideline on the pediatric diabetes endocrinology. It's called the Best Bed BSP the website. Um, yeah. Sorry, I can't remember. Okay. All right. Let's move on. So we're gonna do this one and we're gonna do this section, then we're going to have a quick five minute break. So, Abdul is six years old and presents with 24 hours of cough and difficulty in breathing. He's found to be wheezy and he's given three lots of salve of nebulizer. Be small to lots of ipratropium bromide and oral prednisoLONE. 30 minutes later, he's still wheezy and shows signs of mild to moderate respiratory stress and he appears to be shivering and has vomited twice. His saturations are something that I can't see behind which at his saturations are 95% and a lactate on his cap gas is 4.5. What is the next most appropriate management step? Is it? And I'm an often infusion magnesium sulfate bonus. A Montelukast already Southeast Bolus IV or Southeast nebulizer. All right. So who wants to left? That's personally out there. Copy, you've got the question mark. Copy. Good. All right. And I think that probably that sounds right to me. So I go I would go with that. And is there anything in the question that because you could cause you could think about giving salbutamol nebulizer or salbutamol bolus IV anything in the question that makes you think that that's not the right thing to do? Good question because uh right. And why do you think that has to be small toxicity? Megan's okay. So they're shivering. The vomiting and a highlight eight. That's exactly right. Um So, uh this patient sounds like they are self be small, toxic, but they've had a fair amount is I'll be small and you're now showing signs. So, so again, why are those things in the question? Why do you need to know that they're showing a vomiter twice if it's not relevant? Like why do you need to know that the lactate is 4.5 if they're not talking about him being septic? So if you got popular gas lactate or 4.5, you're either septic. You've got, you've infarcted, your bowel somewhere, you've got to ski me a somewhere or you've got a salbutamol on board probably. And so that's, this is one of the classic questions where it's like, why is that there that has to be relevant? Otherwise, it's just a random thing to tell me. So if it sparks any memory in your mind that, oh, this, isn't that something about that would be small then, or maybe they're telling me that that, that shouldn't give salbutamol and actually, maybe it's something else. So that would be why this one is the most appropriate. I made this in this case. Um Any other complications of salbutamol that he wants to throw out there? Good question. Um Mr uh let's see. So your name uh and we're gonna come on like a few seconds to hold that thought. Any other, any other complications can be small. Yes. So hypochelemia. Exactly. So well done. So, remember in adults, you give them for Children. Actually, you, you give, if you have a renal patient who's got high potassium, you actually give savvy small that your, in your, in your, in your algorithm to bring down the potassium. So if you've got a normal taxi, um it'll still bring it low and then it makes you quite tachycardic as well. So that's the other thing uh increase your heart rate. It's unusual to get arrhythmias. But um but you can definitely get very Tiki Kartik and, and have the potassium. Um question about if they didn't have savvy small toxicity, what would the next step be? This is very much an M C Q S B A question where it's still the right answer to say magnesium sulfate. But if you're writing an SBA, you have to cover yourself and say no, that is definitively right answer. Because if you gave a selfie to Morbo this IV or on and off in bonus IV, that would be an appropriate thing to do after this, like, you know, you could do, you could do that at this stage because you're going to the I V step and of, of asthma management. But the vast majority of people would give magnesium sulfate first. But because there's that kind of like a little bit of a GTI to it, that's why in the question that has to, that has to be relevant. So they have to tell you in the question. Oh, no, actually, you shouldn't be giving salbutamol because of these things that I've put in the question. Do you know what I mean? So it's basically, it's basically saying even if there's two here, I have to differentiate it somehow and it's got to be, it's got to be in the question for you. OK. So just to remind ourselves quickly of the asthmatic stairs. So we've got stairs which are quite asthmatic. So what we normally have and this is where this is the first step is where it differs. Two adults a little bit is what we call the birth step. I think you can sort of think of this as a 3 to 1 and step where your options are. So every most people who are easy and we'll end up getting three lots of Selvi spots and that's either three times 10 puffs. So 10 puffs, space 10 puffs, space 10 puffs, so 30 lbs in total or it's three nebulizers in most settings. If you are in oxygen you get nebulizers and if you're not on oxygen, you get inhalers. So they have the same efficacy. So it's not like, oh, they look sick, whether that's 98% to argue for the nebulizer, it's that you get, you get inhalers. If you are not an option, then you have the option of giving Atrovent, which is hypertropia very wide. The tradition is to do that twice. I personally give it three times because I don't really see the point in it, but most places you end up doing it twice and normally you don't give that by nebulizer because otherwise it's just wasting uh for the sake of windows. Um I've just been given a bonus of Diet Coke, which is, which is amazing. That's 10 mils per kilo and that is excellent. Um Then, um what you want in your 321 is possibly print this length and there's lots of debate about when you do give prednisoLONE and every unit does it differently. Unfortunately, for the sake of your exams for, for consistency. If they are over five and they clearly have asthma or it mentions they have a history of asthma, then it's completely appropriate to give Credits Lane if they are preschool and they haven't got a history of significant a to be or significant violent use reason. The question, generally speaking, it's not appropriate to default gift from this loan and if they are bang in the middle, then I think it's unfair. And so they are three years old and there's nothing to say they've had multiple episodes before or they are allergic to cats nuts, you know, whatever. And then I think it's unfair to, to, to, to expect you to make a decision where they have this, like, but asthma, yes, perry school age with cracking a, to be, yes, under school age with no way to be. No, as a general wisdom. So you do that and then you reassess how they're doing and then you decided they're better or they're worse and we're just going to go on the worst step just to kind of escalate just to kind of sort of let me just remind ourselves quickly. So you have what we call an IV bolus step and where you have some options. So you have three options and you have Mike sulfate. So beautiful and having often were talking about getting a bolus of something stopping and seeing if it works a lot myself is probably got the least um side effect profile from those three. So that's why it's kind of the first one and you just given the shadows some reason why anyway, in the first step. So it's quite often nice to do something quite different. You're clearly cannulated them when you're starting some maybe therapy, you know, um sort of side effects magnesium and it makes you a bit hypertensive. So if you imagine preeclampsia, you give myself and it makes it makes you say less hypertensive. So it's relaxing, smooth, possible does the same thing in your airways. Um So be smart and then I'm an offline and does it move now to go on and offline and then so be small for, for any of those reasons and you can go to an infusion step if you are so still strong. So you're getting all these three and you thought, oh, you've got a little bit better for a short period of time, but you haven't got better like consistently. So what you need is more bonuses. But if you ask the nurses to draw you up a bonus every five minutes, they're going to physically stop that even your eye. So you have an infusion, which is basically a bonus every five minutes, but just a beautiful infusion where you can make it up and down. So that's where you go to have an often salbutamol and infusions. Normally, I'm an often first consider adding a salbutamol infusion and you're still really struggling, then you're gonna get to the panic step, which is to interface the ventilator, the signs that you need to move up each one of these steps uh that you are having significant work of breathing low and so decreased air entry, decreased oxygenation or signs that you have decreased ventilation. And anybody can anyone problems at what a sign of decreased ventilation might be. So, decreased oxygenation we know is those outs right it's very easy to measure for decreased ventilation. Right. Yeah. So potentially what's O C 02 is your marker ventilation biochemically. Right. So, they give you a CO2 that is normal or high, then you'll know from your B T S guidelines. And that is a sign of severe, uh, of severe, uh compromised, so severe or life threatening aspect. And, and the point is that if you're breathing with a rate of 40 if any of us did that, now, our ceo to plummet and we kill off a chair. So if you're doing that with asthma and you have a restaurant to 40 but your CO2 is normal or high, that's abnormal, right? It should be in your boost. So, a normal or high CO2 particular society, you're not ventilating and a child who is tiring, who has a silent chest also, they're not ventilating. So you need to escalate very quickly on the steps, potentially into place and ventilate the, um, throughout that, obviously, you're gonna give oxygen if that's, that's 100 92. And the point of all of this is to try to get them to stretch their cell Wiedemann. And you have come across as I'm sure on the wards. But what they do is any point in here. So normally your idea would be they get three, lots of studies more when they come in. None of the rest. They, then you, you look at them at an hour you think? Right. Do you need to have it more now at an hour or is your air entry good? Is your spiritual stress better? Your saturation is good. And if you say yes to those things, they don't need anymore to be small at that stage, but they do, they, but they can move on to, to hourly. You go back and review them at two hours, right? Do you need it now or not? Oh, you do? You do need it now because you're working a bit harder. So you give this upbeat smile again. So it's 10 puffs again or one nebulizer and then you reset the clock and you go back to the top again and you're like, right, how far can you go this time? Can you get to two hours or three hours now? Now, this time it's like, all right, three hours. Yeah, you need it three hours. Okay. Let's go back to the top again and then you start again and once they can get to four, Allie Salvi's also the first time they make it to four hours. That is when they can go home and normally continue a week plan at home and to, uh, to give for ourselves smaller than they say for us at home and then reduce, uh, from the okay. But although this looks complicated, there's not that many medications on here. So the Salbi Small, which pops up everywhere. So even doubts. Abbey smells always, always an option and there's mag self, which is probably the first line on the IV. Bolus step. There's aminophylline just to be aware of on the, on the IV bonus and the infusion step and then there's pregnancy line I try to be and I don't think that they're going to ask you to make decisions about extra because food practices really varied. But it's more apprentice load max health coming off lip, there's only five medications there to, to get your head around. So it's not actually too much when you think about it. Yes. So in 321 approach, it's always 10 puffs of salbutamol and, or a nebulizer. Um So that's, that's, that's the kind of classic. Again, some hospitals will say, oh yes, saturate receptors of five puffs actually, maybe that's true. But the tradition is 10. Um And, and as you can tell pediatric medicine doesn't have a huge evidence base behind a lot of the really common things that we do because it's really difficult to do very large are CTS on Children. Um But you, the Atrovent, you don't give a nebulizer so that you would normally begin after that and you do is probably two puffs, but you don't have to do that. And then the prednisoLONE is always walk. Yes, if you are going to cannulate them and you're gonna move up through the things you can think about getting hydrocortisone. And I always remember like hydro is water. So it goes through the vein, hydrocortisone only goes through the vein bread. This leg go through your mouth. Okay. Right. Let's just think about a couple of questions about that. So, Georgia is brittle asthma and he presents with a severe exacerbation. He's currently on an an offline. So piece of my infusion. His auction saturations are 92% on 15 m and he appears to be tiring. What is the most appropriate next management step for George? Do you want to adjust to take an aminophylline in level and justice dose accordingly? Do you want to give him that trend? Nebulizer, hydrocortisone IV, intubation transfer to pick you or magnesium sulfate by this IV. Yeah, I've got some Ds coming out. Anyone want to disagree. Yeah. So that sounds right. Um So we know that that's, you know, when you're on animal often subject infusion, you are at the top of the tree. And so getting worse after that, we know that you're tiring and that's a sign that you're not ventilating. You're really strong to maintain the oxygenation. So that's a child who needs to be intubated. Um You know, you're not gonna be able to fiddle with them off level. It's gonna take ages to come back naturally. It's not going to do much good at that stage and they're on 50 m. You actually have to give eight liters through a nebulizer. So you're gonna take auction off them once you do that. Um Hydrocortisone IV is not going to work quickly enough and, and magnesium sulfate is a step down from having often and to be more rather than a step up would you can transfer to H D, you'll pick you earlier if needed IV access. So normally most of this will happen in E D. Um So you're like, you're trying to, what we try to do in, in, in, in E D or um, well, if you're super sick, obviously need to be in an E D recess environment and it's top out as severe as they're going to get and then sort of let them then get better in an H D U setting. So if they are on IV S and they've had IV therapy in most, in most tertiary hospitals, they'll go to H D you and in most DHS, they'll go to the H D you part of the normal ward, which is normal, just a bed that's like six. Um So they are needing IV S, they will need a high level of, of uh nursing care pretty much, which is why they get to each to you and then once they are off IV S then they can start stepping down. Cool. Right. Josh is four years old and presents with a 24 hour history of cough and difficulty breathing. He's had three previous similar episodes and he has exponents allergic to peanuts. He was found to be wheezy and was given inhalers. Uh I can't reply the charm. Sorry. But at, at some beautiful match mental presentation, you review him one hour later and he appears comfortable with no wheeze and good air entry. What would be the next appropriate step in the management? So, do you want to discharge him? Homosexual, getting advice? Do you want to give him Max Sulfites? IV. Do you want to give him Montelukast orally? Do you want to give prednisoLONE already an assess? Within an hour? It was give salbutamol advice. Basal one hourly. Yeah. Right. Some tape lunch. What are you thinking? Okay. I've got some teas and that sounds right. Okay. So given what we said, we know that he needs to so to take them in order, we need to. So this one's sort of a bit more of an awkward one like maybe that's, you know, there's a few, a few things here and people were less, less willing to come forward straight away. So just thinking about trying to sub these down so discharged home with technical advice, that sound like a good idea. We know that they know we have to get to four hours after their, after they've had the best therapy twice so that we can just discount a Magnus himself. HIV, we've been told that he feels comfortable with no reason. Good air it ori so we know we don't need to escalate. So like, so Max L5 E, we know we let me to step ups that can come off Montelukast orally, that can probably come off as well. Actually, because we know that's not an acute drug unless you go to Chelsea. It and it was still do that Chelsea. And when I went there that we used to give you cast already, uh instead of present state, which is, isn't back over there. So they could put some clever people than me came up with. And it's a beautiful vice basically by a space of one hour, a possible, but we've been told that actually we're looking at them or one hour and they've got no reason good air entry. So actually, they probably don't need them to be small that quickly. And so what we do know about them is that we've had that there were that they had multiple previous similar presentations that they have expert and that they're alleged to peanuts, sorry, that hasn't pulled through on the slide. And, but so we know that they have good atopic history. So they do need some prayers and they didn't get it when they first came in. So that's why it's just to be aware that medicine will act slowly. It takes about four hours to work. But it's something which they will benefit from because they're perry school age and they've got a good history later. Be okay. Katie is three years old. She's been admitted to hospital four times with wheezing and required IV medications once she has X men will start on low dose inhaled corticosteroids. After her second admission, she presents to follow up clinic and her mother tells you that she's using her blue inhaler. At least once on most days. She wakes frequently overnight coughing. What's the most appropriate advice to offer? Should she be admitted test for, for sleep study? She, she start a course of oral corticosteroids. So, inhaled long acting beta agonists start Montelukast once a night or you serve use more, more frequently. Okay. Okay. Teas. That's one uti actually is number 33, Legacy DS from the last one. What do you anyone else say at the most? Good? All right, I agree. Um So we're done. So, just thinking about our options and um it hospitals for a sleep study that seems a bit brogue. So that could probably come off. So of course, of oral course of hysteria, she's already on some course of steroids. So you're not the worst idea in the world, but it's not going to solve things long term for. And all of course of steroids is now patient's are quite a significant step. That's quite high step on this because you're looking for preventers that are not gonna have side effects. Basically, the oral course of steroids are gonna have side effects, making it regularly starts inhaled long acting beta agonist. That's very much a possibility. Right. That was, that is very much one of the next steps in your management options. Start Montelukast one tonight C or D. For me, you sell these one more frequently. Sounds like a bad idea. So we know that if you're using services or three times a week, it's normal time to step up to another preventer. And so thinking about BTS guidelines basically, normally. So the normal thing is to start on a low dose, inhaled cortical steroid um as at any age. But if you're under five, consider Montelukast, then where it gets a little bit sort of more complex is basically to say, well, the second step, if they're on a very low dose, inhaled steroid already, then if they're under five years old, Montelukast will be your next step. And if they're over, then a lab, it so a long acting beat, irregular slice albuterol, for example, would be your next step there. So it just matters if you're, if you're on the younger enter spectrum or if you're on the older end of the spectrum. And so your first two and under five should be low dose in the hills steroids plus Montelukast and you can do that either way around. But on this, in this example, they've already, they're already on a low dose, inhaled steroid. So if the Montelukast will already be the most, next, next most appropriate step. And then the third step, you either increase the steroid dose. So they can be on a slightly high, they can have two puffs into the one, but for example, um or stronger uh areas we can add a lab or if it's not already on. So basically, next thing would be to say, right, take a combined inhaler with both long acting agonist and there's a story together. Plus you wanted to cast, which you already started, you're under five and, and if they're under five at that stage, they need referral. Uh and then that's when you're thinking about other things in the community which were relatively rarely use like the office, which is going on medication, which is, is tragically rarely used. And, but the headline from that is always, do always think about very low dose and uh inhaled steroid first either under five, then think about Montelukast. Oh very five. Think about lava and then adding whichever one you have. It already does okay. Right. Um Should we have a three minute break? Would that be all right to go and get yourself a cup of tea or other beverage of your choice and, and feel free to ask any questions in the meantime? But can we be back at back at 7 20? Is that okay? And then we'll try to, we'll try to skip through the rest. We might be sort of depending on what you guys think. We're probably looking at another maybe in about an hour. So it's somewhere around 88 20 obviously go if you need to go and feel free not to come back from these three minutes and you think that this is rubbish and that's your choice obviously, uh disease being online. But yeah, let's come back at 1920 but feel free to asking the questions anytime. Okay. Yeah. And Right. OK. So it's 20 past um quick question in the chat. There was whether uh whether it's worth going to moderate uh strength Cortico Series um in practice, you could consider that you definitely consider that for the slightly older, the slightly older cohort. But for the younger cohort, there's a little bit more anxiety, more anxiety about kind of the steroid use, particularly the small preschool ones. Um So it's low dose. Yeah, it's just low dose corticosteroids. So LTs. Um and it's the same thing what you sometimes do for them is actually we start 11 puff and like I say, it's like 50 mix and then actually you'll make it, you make 100 mix, but we don't make a difference between those two things. It's still just low dose. Um And then yeah, but it's just, it's just to be aware that Montelukast is uh is an appropriate thing to do first and and it may be that, you know, again, how are they gonna differentiate that in a question for you? So it may be that mom has mom has significant concerns regarding steroid use or mom had like uh older child has had multiple steroids and then I got because she or features or something like that had this heads, right? They don't want steroids. So I'm gonna give one to do custom statue. So they have to differentiate it for you, right? OK. Are you feeling hopeful? You're feeling normal glycemic and normal intensive. Um And we can continue this, you're gonna have to dig in for this one a little bit and this one's um this one is the section that everyone really loves. Um Can I just let it go to remind people just to put themselves on mute if that's okay, just having some background noise a little bit. Um If that's all right. Um Cool. I'm also going to keep swinging doctor because I was in hospital of 4 30 this morning having mental finished at midnight. So I am very much continuing to keep my caffeine levels high, right? So question for you are called to a and e to see Billy who's a three day old baby. The nurses concerned that he's breathing quickly and he appears pale. He was born at term to a low risk pregnancy and required no resuscitation. There were no risk factors for sepsis. His antenatal scans are normal. His restorator 65 as heart rate is 100 and 80. His cap refill is four seconds with cool peripheries. Peripheral pulses are difficult to feel and he appears pale. He has normal heart sounds of the chest is clear. His blood sugar is behind by chance, but I think it's north. What is the single most likely diagnosis? So, his blood sugar was six again. So, does he have a cardiac arrhythmia? So, have cooptation of the auto, so have congenital pneumonia, hyperplastic left heart syndrome or an inborn error of metabolism. Okay. What do people think? Yes. You mean any much attention to break? Got a big question mark. Well, I think we'll employ a, thank you very much. Sorry. Um, let's see. So I think we'll employer strategy from now on that, we have to get at least three answers, three people answering every question just to, just to kind of progress a little bit. I feel free. It doesn't matter at all if it's from these, like some, some of these will be very easy and some won't be a bit more difficult, right? We've got three people, got four people now. So we've got three B's and one C. So, and should we just have a think about what's in the question? So, I agree. I think it's B and so cardiac arrhythmia. Why? So it's not a cardiac arrhythmia probably because the heart is probably not quick enough, right? So 1 60 is normal for a neonate, higher end of normal. So 1 80 is only just over that and your normal looking at 2 20 to be a proper sort of S U T or other cardiac arrhythmia. So it's probably not that um, congenital pneumonia. So it's a, it's a, it's a completely appropriate thing to, to say because they can't be, for four seconds. They could, well, but they could be septic, their breathing very fast and, you know, they might have signs of sepsis. So, anything there that sort of maybe try to steer you away from that record, genital pneumonia? Yeah. Okay. So, the chest is clear. Exactly. So the chest is clear and also the, where it says that there were no risk factors for sepsis. So again, why have they told you that? Like they didn't want to put like they're not trying to give you a whole like thing yet the case, although sometimes it seems like it uh you know, they, they said that because they're trying to see you away from the, from the infection probably a little bit trying to weigh up the possibilities of what's going on. Um So make that make makes it less likely. So we're looking for the single most likely diagnosis, you know, it's possible, but it's less likely because of that hyperplastic left heart syndrome. What what takes you away from that one? So normal heart sounds. So heart sounds are normally value in nature. So you can have normal heart sounds but have a very abnormal heart. But yes, normal antenatal scans. And so the scans look very nicely at the heart itself and the kind of architecture of the heart not quite as good for stuff outside the heart, but again, maybe it's trying to push you away from intra heart stuff by saying that those scans were normal. What moves you away from an inborn era era of metabolism, normal glucose. Exactly. All right. Well done. Okay. So there's, there's stuff in there that's pushing you away from other things and then the stuff that moves you towards coarctation of the aorta. It's like a pneumothorax. It's like it's the media's, I'm being pushed that way. It's being pulled that way by collapse. So you've been pushed away from the other diagnoses that you're being pulled toward this one. Probably because of the uh difficult to feel I would imagine. So we're talking about probably probably femorals there. That could be a little bit more obvious. But whenever pulses are difficult to feel, you got to think there's an obstruction somewhere in there in the blood flow to, to them. And cooptation would be a classic one. So strongly to feel pulses. Think of connotation does everything always makes sense. Yes, probably. And just as a typically you don't need to know for your, for your exams. Do you know that in adults, the apparently the most, the most sensitive marker that they're going to need to go to a to you in the near future that they're going to collapse, is there a spiritually, whichever one kind of always gets? But the reason that the marker is whether their respirators even or odd number. So whether it's 13, 15, 17, 19 or 14 16, 18, 20. And do you see a respirator? That is, um, it always stops me now, whenever I see a respirator, that is odd because it means that the nurse stood there for a whole minute to see, to see what the respirator actually was. Like they cared that much that they thought the childhood, the child or the adult, was that ill? They waited there for a whole minute and didn't times it by two or four or six. Could I go for 10 seconds? 15 seconds or 30 seconds? So, actually spent some time with, with Qantas. So it's just a little bit of a tip. Bit of a kind of human factors. But respirator 65 is worrying in itself because someone actually stood there and cancel them anyway. So when a baby collapses, there are six likely diagnoses that have got to go through your head. All right, anyone want to just pop those in and we've sort of, we've already discussed it, but just to kind of populate the chance, what are those, what are those six likely don't make this, do you think? So, you got a baby who is, let's say under two weeks or a year later and four weeks who has collapsed appears very unwell respiratory issue. Little bit, little bit vague. That caused by what sepsis. Yeah. Yeah. OK. Hypergly seeing it and then this to this team all. So number one is sepsis. Number two is also sepsis and number three is also sepsis. All right. So generally when things go wrong with babies, the most likely thing is they've got a severe infection. And then thinking about like risk factors for infection from around pregnancy of rebirth is helpful and kind of delineating that um particularly MCQ, whether or SBA, where they've got to give you something to go on. And that's the first thing goes through that the other things which can cause you to deteriorate rapidly in this, in this kind of age group, congenital heart disease. So any congenital heart disease, um metabolic stuff. So I'm just gonna call it metabolic badness. But I basically mean inborn errors in metabolism. There's not too many of those that you really need to know in huge amounts of detail and you can spend a lifetime trying to figure them out for your exams. I think you should concentrate on more hardcore things if you have more like relevant and bigger topics. But the only thing you need to know about that is if your glucose is low and particularly your lactate is high, then there's a problem with your metabolic pathways. So you're not making enough glucose and you've got abnormal ways of trying to make energy in your body. So whether that's the uric acid cycle where it's the amino acid cycle, whether it's the fatty acids, whether it's like in the genesis, whether it's glycolysis, like whatever it is, like, there's multiple cycles that make your metabolism and you're lactating your blood sugar are the two markets bit. So if you have a normal blood sugar, you probably shouldn't have a metabolic problem in the context of this kind of question. And if you have a low blood sugar with a highlight eight with the higher movie a thereafter, then there's an inborn error of metabolism and there are many and uh I would spend a huge amount of time learning. Uh It's normally gonna be something you haven't really heard of. It could be like PK like PKU is a classic one through a test for it. On the guthrie M CAD. It's probably something just to have in your brain as well. Maple syrup, urine disease. That kind of a plastic ones because they come up from the guthrie five day testing. So we can actually do something about it. We know about them, but you haven't got your five day screening back by, by this stage and N A I is the last one. So nonaccidental injury. So it's just always got to be in the back of your head. And this is more of a clinical thing. But again, in the exam where baby has collapsed, it's probably on this screen like it's either sepsis, it's heart disease, it's metabolic, all the sub social stuff in there. And the baby's actually had a big bleed. So like an intracranial bleed and, and they quite often collapsed from that maybe have a seizure, um, to do it as well about trauma. So, just keep that in the back of your mind. Oops, please share that again. Right. Okay. Are you up for a quick, a quick overview of congenital heart disease? And that's sort of a vaguely rhetorical question is if you have been through this a lot and you don't want to go through again, then that's fine. I find most people quite like a sort of a dummies guide to congenital heart disease just to at least know what we're sort of vaguely looking at. Okay. Is that all right? So you've got heart is beating. Um, you got two sides of your heart, you got right side on the left side and then you've got your valves okay. So if you have a right sided heart problem, anyone want to pop out there, what you are potentially likely to present with if you have a right sided heart problem? Interesting. So it's good thought, Jack. So, fluid overload as in, if your right heart isn't able to, to pump blood, then you're gonna see signs of fluid overload, which in a baby you might see is Hepatomegaly, you might see his peripheral edema, but the most common cause of right heart failure is left heart failure, right. So it's actually normally that you're not gonna get home edema from the right heart failure because you're not coming into the lungs. So actually left heart failure backed up in the lungs backstops to the right side, then you get for, for edema. So that's more of a left sided problem actually. So right sided problem is normally the color of your blood. Okay. So you've got blue blood on the right hand side of your heart. And if you've got a problem, particularly congenital problem, which is quite often a hole somewhere or a shot somewhere or something that shouldn't be there. Then if you've got a problem where, where the blue bloods going, that quite often goes over onto the left side and cause you to be signed those because if you get blue blood going to the left side that goes around your body, that that's where we pick up your hats and you're gonna be signed those. Okay. So if you see cyanosis, it's probably a right sided problem. And there are some, there are some, you know, there are some exceptions to these rules. It's just a way of thinking about congenital heart disease. If you're on the left side, that is your pump, that's what's pump into your body. And so in extremist, you're gonna present in shock like like like this one kind of did. Um And otherwise you're gonna present with, excuse me, signs of failure. So Palmer Edema Hepatomegaly because your left side is failed and that's backed up all the way around uh into your legs at the up. But if you've got a problem on your left side, most of the time you should necessarily be signed nosed. Cool. Um So just to think, I think it's, I think it's good to think through the heart of where the blood goes. To think like why your side, those on one side and not on the other and what some of the conditions can be on, on your way. So, problems in the right atrium, these are mainly valvular problems and throughout the heart, it's mainly valvular. So this is your great tricuspid valve. On the right side, you can have a tricuspid atresia, which is where the valve just doesn't, doesn't form properly and it isn't functional. We can have Epstein's anomaly, which is a nice kind of again, medical student, a part of a name to know. And that's where you've got an inferior lee displaced valve, which is dysplastic. So it's kind of a non functional way, barely functioning tricuspid valve which causes less severe symptoms to try customers, easier but still severe. So just quickly and someone might have to just a news if they want to answer this or pop it chat. But if you've got no tricuspid valve, for example, where is that blood? How are you still alive? Where is that blood going? Yeah, well done Emmanuel. So you're probably going through an ASD, right? So you, you have to get out of the right ventricle, the right atrium somehow and you have to get to the lungs to be alive. Okay. So, you might shunt across an ASD and, and that might be sort of the foreign avail which is, which will open because it closes with pressure. So it might open with pressure and to the, to the left side or it might become just that you've got an ASD there, if they're gonna go into the left atrium. So I'm going to go down into the left ventricle, but that's just gonna go to your body, right? So how now does it get to your looks? Yeah. Good thinking. So it could be, it could be a P D A two painters doctors arteriosus. Okay. So from your aorta into your pommery artery, but you can see that as soon as that blood has gone from the right atrium to the left atrium, it's now blueblood, right? It's all purple blood. So you're now cyanosed because there's a problem on your right hand side, you've had to shunt to your left to bypass that problem. And that's made you sign nose, the fact that you might need your pee there says that this may be a duck dependent lesion as well. Uh And the other way you can avoid that is if you've got A VSD, just coincidentally, you've got A VSD there and that might save your life because you're shut back across to the other side and then get your lungs and be able to get some oxygen. So you'll be running sats, you know, sixties or seventies or whatever. Probably because you're something across, but you'll still be alive. And if that, if you don't have a VSD and your Pedia shuts, then you're in trouble. Very good question, Gazelle. So, and the Duchess Arteriosus traditionally closed about day four or five of life. So it's a classic MCQ question. SBA question to have a child who collapsed on day four or five of life. This was day three, which could also be duck dependent if it's a severe car lactation. Um so called the postnatal ward on day four or five or patient comes in day four or five with this kind of picture with no signs of sepsis whatsoever. I think cardiac, I think of doctor pepper vision. Okay. All right. Just moving on down where the blood flows. If it's got through the tricuspid valve, okay, because that's normal, then you might have some of the other stuff going on down at the down in the right ventricle. So, Pommery stenosis or pulmonary atresia pretty rare actually. But if you had a critical pommery stenosis, for example, you can imagine that you'd increase pressure in the, in the right side of the heart when you start shunting over to the other side. So that may well cause you to be signed notes. And then fellows, anyone want to give me? Well, I tell I'll save it. I'll save you debate because I'm sure a lot of, you know, but tetralogy fellow is an absolute classic med student questions come up as you might imagine. It's four things, but it's not really for things. It's two things. Okay. So you only need to remember two things for Federal Trelegy. So half the difficulty and you have to remember there's A VSD but the VST is the most common congenital heart disease, right? So you can have that for free, just like VSD for free. Pop that one in there. That's number one and number two is an overriding aorta. Okay. So basically if you've got your, your pommery outflow, which is like normally this wide, but you've got an AORTA that's sitting on top of it like this, then you're going to have a Pommery outflow, which is now only this one instead. Okay. So you've got obstruction of your pommery outflow or your right outflow tract. So you've got an overriding aorta, you've then got right outflow tract obstruction that just causes that. That is something which causes that. And if you've got right outflow tract obstruction, it's like upon Rescigno system, it's not the valve because it's just sitting over the top of it, then you're gonna have right ventricular hypertrophy. Okay. So it's, it's not for random things that you just have to remember because your students and that's what you have to do to get through examples in the works or true. Yeah. VSD for free again, overriding aorta which causes right healthy tract obstruction, which causes right ventricular hypertrophy and you can imagine that if you've got right ventricular hypertrophy and an obstruction to getting out of the right ventricle. And you've got already made VSD. So you've got a shunt, then you're potentially going to be signed nose into Trelegy fellow because again, you're gonna be shunting blue blood to red blood. And what you very often find is you may well come across tet spells, which is the tetralogy spells where a patient who is otherwise read will go as a big, you know, more color will go blue for when they're crying, for example, because they've increased their thoracic pressure so that there's more, more pressure against the right heart's got to push up against. So there's more pressure in the right ventricle is going to start shutting the other way and you also get spasm in the right heart to get what you call infundibular spasm. And then that shunt again, that makes it more difficult to get blood out that right ventricle. So it's just going to start going across the VSD instead. So that would be an example of a potentially cyanotic heart disease, but something that can shunt across the BSE OK, following that through. So continuing to follow the blood, we're going to talk about that. So just very quickly in the and I put this in the right ventricle. So A VSD because we've just said that if you have enough pressure in the right ventricle, then A VSD, of course, you can be signed nose, but the vast, vast fat, the majority as in nearly all the stds, if it's just A VSD by itself is going to be, your left heart is stronger to your left eye. It's going to pump red blood across the right side to A VSD. Well, normally cause side to failure after a few months because you've got more blood going to the lungs and you're having to pump more blood and it's kind of backing up. That's kind of kind of classic presentation of the ST and then another classic medical student and upon a syndrome to know is called Eisenmenger's. And that's when you shunted. So for so long from the left side to the right side, the right side becomes so strong and so overwhelmed that it just starts cutting back the other way again and says I've had enough of this like I'm now stronger than you are and I'm shunting back to you in the left side. Unfortunately, you've changed the architecture of the heart then and that's normally kind of a pre heart transplant kind of situation. It's kind of non reversible point. Uh Bison Burgers is where they have a V stds who are practiced on a murder. They've had signs of failure, it's been untreated for whatever reason. Maybe they've been outside the country, maybe it's not been picked up for whatever reason. And then it starts something about the other way by the same logic we've looked through the right side, left side, you could have mitral stenosis or atresia, extremely rarely atresia, uh, in my experience, but you can have valvular problems. But again, if you've got a mitral stenosis or mitral regurg for that matter, again, you can see you're not gonna start shunting, you're not gonna shunt blood the other way probably. And you're definitely not gonna shunt blue blood to read. So you're not gonna be cyanosed and looking down the bottom of the left ventricle things to know about our hyperplastic left heart. Um I can't move this chat again. Um I've got cocktail so hyper fast let hearts where you have the left ventricle just doesn't form appropriately. So you've got no pump and you've normally got a non formed aorta as well. And that's one that could be sinus because you're going to need to do some switching of the of the circulation's. So you're gonna need to mix because you're normally working on one metrical. You could have a cooptation. You can have no um interrupted aortic arch or an aortic stenosis or critical aortic stenosis, which is one of the aortic stenosis would be one of the common ones. And again, you can imagine from that you've increased pressure in the left side. But even if you've done that, you start shunting, you're not going to be signed nosed, but you are gonna have signs of shock if it's really bad and potentially failure. If it's becoming a little bit slower adding to that, that you've, we talked about the heart now. So we've gone through the heart and we've not really talked about very many things. We've only talked about valve and the lesion's tetralogy of fellow and then holes and then the extra want to know about is transmission of great arteries. And I'm sure you've come across that before, but instead of having blood which crosses over between going from the left side to the body to coming back to the right side, you've now got the aorta where the palm, yeah, should be the primary artery where the aorta should be. So you've got blood coming out of the left ventricle into the pulmonary artery, going to the lungs and then coming back to the left side again. So this thing down the middle is completely like the blood will never cross the middle. So it will just go like this to circulation's. So your lungs will be doing great and they'll get loads of up to oxygen to them. But your brain and your heart and your gut will get an option to them because they're not connected. So again, that would be one way you need is a connection between them. So either A VSD, if you're just lucky that you've got A VSD there, that's going to keep you alive or A P D A. And if that closes around day four or five with a sign, those patient transposition is a really common scenario. And I'm mentioning a VSD which is uh atrioventricular septal defect, which is just kind of in the middle where there's just a big hole there. And there's, there's problems on both sides of the atria and ventricles because that's the most common associated with Trisomy 21. And it's just a sort of, it's not a pattern ammonic kind of thing, I don't think, but it's, it's for your fuel purposes that's normally associated with them with Trisomy 21. So that's just meant to be, oh, I keep doing this where I go back and just do the thing. And so that's just meant to be a very, very simple overview to think. Where could this be coming from? So if you get the congenital heart, quote, question is like what diagnosis it is? It's I noticed it might be on the right side. Is it shocked or, or, and failure? It might be on the left side and just work your way from where the blood's going and there's not that many options that you have to know about. Okay. So like you can, I think you can conceptualize that and you can see where the room is like, you know, you walk into the congenital heart of the room and he's like right where the, where the walls, where's the ceiling have no idea where I am. Hopefully this scheme, it just gives you an idea of roughly where you are and roughly how to work it out. Another thing is the timing of the presentation. So it's in the first few hours and you can think of like any Trisha. And so something that's just not there, which has to be there to survive. So they're collapsing very, very early or the really critical stenosis or critically or six notice where there's just barely any blood coming out of the heart or hyperplastic left heart syndrome. And where and where again, you just not got the pump going to something catastrophic is happening very quickly. The first few days were looking at the the doc dependent legion's to transition to travel transmission. Um A large pee might present in that time cooptation if it's um in um if it's either severe or doc dependent first few weeks, less severe aortic stenosis or cooptation. And then the first few months we're looking at um normally left or right shunt like of the S D in the first few months of them just getting more and more sort of besides of failure and poor feeding. So just think about putting some of that in practice. So you are called to see Ebri um who's a 24 hour old baby on the postnatal ward. The midwife is concerned that he's breathing fast and that she cannot pick up accurate. Saps. Ibrahim was born at 37 weeks. His parents have recently arrived in the area and no international history is known on examination. Ibrahim appears dusky in color. He's very technique and tachycardic and he starts at 72% in there. When you add 15 liters from a non rebreather bag, the that's a 74% and you can hear a great 1 to 2 machinery man. Murmur at left sternal edge. What is the most likely diagnosis? Is it cooptation, congenital pneumonia, hyperplastic left heart syndrome to Trelegy, a fellow transmission of the great arteries. Okay. I've got to ease the whole thing. Company. Anyone else want to tip up a third one on there too. Our new new system there, we get Thinking Arena. Okay. So, I agree. That's probably an E and issues are that we are cyanosed. Okay. So we are decreased at so cooptation, we ought to probably not going to make us cyanosed, right. We've got blue, we've got a red blood coming down and just getting a bit stuck. Hyperplastic left heart syndrome is possible and it's a challenge. Your fellow is possible, but this person is a little bit sick and we've got to want to machinery mur murmur rather than a kind of a proper pansystolic VSD murmur from to travel. Gee whereas trans position is someone who is very silos doesn't come up with oxygen. So, congenital pneumonia, the, the oxygen levels should come up when you give them high flow oxygen. And the machinery murmur is probably the, the, the P D A that you're hearing. So you do have a patient doctors arteriosus um here and you can hear it as a machinery member. That's what it normally sounds like. It doesn't exams anyway. Um, the fact that there's no antenatal history known um is important because that's raising the possibility of a significant cardiac lesion. Um saying that, you know, they may not have had any, any antenatal scans um that we're aware of. So they're kind of again putting that in to say, rather than sepsis, that's maybe sending you towards the structural problems. And so you've seen the same person and you can hear this machinery murmur and the SATS are very low and you think it's a transposition, what's the, what's the most important immediate management plan? So you want to give them a temp Akilah bolus of Northern since island, do you want to give him high flow to, do you want to give, do a metabolic it screen including ammonia? Do you want to start prostin IV infusion which is possible only two or you want to start Ampicillin Gentamicin IV great three straight in there to say that prostate Latin is the way forward. Okay. So imagine your duct is closing your doctors. You're only lifeline between the two circulation's and the way to keep that open is to give some prostaglandin. You can also do some of the other things actually to be fair. So you can give a temp a kilo bolus and that will also help keep that, that duct open because you've got more fluid going through it. So it kind of like resistance and closing. And in any child who deteriorates, we know that sepsis is high on our agenda. So I would give them ampicillin gentamicin anyway, actually, or Ben Pen agenda, but it's not going to save their life in this one because we think we know what the diagnosis is. So if you think it's a duck dependent lesion, then prostate infusions way forward. Just remind you that the ducks, you can see the pedia there on this diagram is between the aorta and the pulmonary artery. And, and so that is your connection between those two circulation. So if you've got an obstruction before that, so like a critical obstructions somewhere or you've got the arteries over the wrong way or you've got a critical consultation, for example, before know blood's getting through, then that blood will either get from your, depending which pressure you've got from your circuits, systemic circulation to your lungs or vice versa. So some of the classic ducks, pedal visions are severe pain with stenosis, pulmonary atresia, Epstein's anomaly severe cooptation, particular one that is above where that's where that dot comes in because if it's after it, then it doesn't matter if you got a doctor or not critical aortic stenosis. So again, an obstruction before where the doc comes in hyperplastic left heart syndrome. A problem with your, with your, with your pump before where the doc comes in and that's right side and left side and signs and then, and the transmission of great arteries would be the kind of the both sides that your doctor pendant. Remember, doctor benign lesions are normally presenting in the first five days classically day, 3 to 5. Okay. How do we feel about that? Do we feel uh do you feel that shed any light or just has been, has been uh I mean, these are revision lectures so that, you know, you can't go everything into everything in great detail we're trying to go through and just kind of give an overview, but hopefully that's helped to kind of contextualize some of that congenital heart stuff. Any questions on that before we move on? Good appropriate time for questions left. Moving on to the next question. Okay. Cool. Right. So question five, Julia is a six month old who was born at 33 weeks. She presents with four days of equity breathing and the cough, she has a runny nose and a fever of 38.2 degrees and auscultation. You hear wheezing crept bilaterally and she has significant recessions which investigation is most likely to reveal the diagnosis. A blood culture, a chest X ray in these apparent you aspirate and her nasal swab or throat swab. I have a D and I did at least two more for the referrals. I have a seat question mark. That's her and I have a seat with your question mark. Thank you. And, uh, okay, there's a bit of a, there's a bit of a random question but it's, it's basically to, to reinforce what's going on. So, the diagnosis here is actually it's a long word spells then that's when we're not coming quickly enough that bronculitis. Right. So, the question is how we're going to say we've got a child under one year who's got difficulty breathing and critically has got weeds and crabs. So, weeds and crops together is a classic and sort of auscultation of bronchiolitis. Kreps just by themselves. I think you may be more effective. So, like you've got focal cramps were thinking more pneumonia but generally scraps with weeds, bronculitis, particularly low grade temperature and coryza symptoms. Um, so broncholator is caused by a virus, blood cultures not gonna help with that. You don't need to a chest X ray in uh pancolitis a per nasal swab. Anyone anyone want to say? Well, that's what that's for, that's for one specific thing. No whooping cough. Yeah, well done. So, per nasal. So, or pertussis and we've been coughed. So that's what, that's what you do for that throat top is normally an empty and s so we're looking for kind of strep throat on a, on a throat swab normally. So, an NPA A nasopharyngeal aspirate is normal looking for a host of viruses and there are many things which can cause bronchiolitis. RSV is obviously the most common rhinovirus, enterovirus, Padinha virus, MetaDerm A virus, power influenza virus, 123 and four influenza virus COVID. You name it, it's around your special tracked. It causes bronchial isis. But in this case, knowing that they've got a virus would confirm the diagnosis just to be clear. We don't need to do that. We don't know this is a clinical diagnosis and the bronchiolitis. But if you admit them to the ward and then you normally need to cohort them. That's why they quite often end up getting an M P A and then that confirms which virus you've got. So it's a little bit of a kind of a abstract question to say what would confirm the actual organism or maybe, maybe that should be revealed the organs and rather reveal the diagnosis. That's my fault. But this is what this is what you do to reveal the organism, which is causing your symptoms. Okay. So Julie, a six month old baby is born at 33 weeks. She presents with a four day history of difficulty breathing and a cough. She has a runny nose in the fever of 32 degrees. Question. What? Sorry, why can you not do upper nasal sort of uh the bronchial isis? And if you ask for upper nasal swab, you basically just get pertussis and pertussis is a bacteria, right? So you are looking for viruses. Um I think the real question is if you just stick it up their nose. Why do you not get the virus? And I don't know, that's well, but normally it's not, it's nose and nose and mouth, I guess, like COVID in some ways when you do that, kind of like you normally do the both to kind of be to get as many secretions as you can. Uh That's a good question, but just know that upper nasal will be rescued for that. You're asking for pertussis. Uh and then you're asking for general respiratory viruses. And so the same child, she's four days history of difficulty in breathing, but now she's got these new preps and she's got some moderate subcostal recessions. Her SATS are 89% on their, she's feeding around 40% of normal. What's the most appropriate initial management plan? Do you want to put on some CPAP and an N G tube fill feeds? Do you want to give us some inhale Selby, small nasal cannula 02 and encourage her feeds? Do you want to put nasal cannula 02 and N G tube feeds nasal cannula to your Augmentin and encourage breastfeeds or give nebulizer be small, nasal cannula two and an N G tube feeds. Okay. I was seeing E I put one upset. Anyone else want to pop in? That's wrong. I've got t anybody else. Of course. See, see question mark. See cool. Okay. So a bit of a spread, I think C is probably the right thing to do here and there's one bit as well. There's a couple of reasons why the others are appropriate. So, let's leave a for a second and be, isn't appropriate because Selby's one doesn't work for bronculitis. Right. Are we happy that you can't give, you don't give inhaled pizza agonists to bring politics and you, we could encourage her all fees, you know, but she's under 50% of normal, which normally means that you need a bit of extra support. Um Jack answer to your question, is it in between inhaled and mobilize salbutamol? Um In theory note, so it's the same efficacy, whether you give it inhaled or whether you get stabilize, it's just the delivery method. So the method is that if you, if they need oxygen, then they get it through oxygen and if they don't need option, then they just get it through air, which is an inhaler. Um in practice you, when you give a nebulizer, you get a load of steam and that probably moved around quite a lot of mucus. And so some babies do look a little bit better after they've had a nebulizer. Well, paradoxically a little bit worse because they moved the mucus um to a worse area. So you can change how they look by giving a nebulizer. But the actual active ingredients have the small won't help for these, for these babies. So, no, there's not a difference. But practically speaking, if you're actually an award, then Yeah, you may see some difference. You just got to understand what's caused that difference rather than the actual piece of agonist activity itself. Um So we're not gonna give Abby's mom. Uh CNA can kind of stay on our can be are two that are staying on our agenda for now. Um Nasal Canonero to sounds sensible or Augmentin and courage, breastfeeds. My problem is all augmented with that. So this is bronchiolitis. This is by definition of virus. It's a clinical diagnosis. It is caused by a virus unless they are far more sick than you expect. They've got focal crepitations um or they've got rip roaring signs of sepsis. They don't need antibiotics. Okay. So you don't give antibiotics for bronchiolitis and then last one and they'll be like salbutamol. So again, which gives salbutamol for, for bronchiolitis. Um So you can take out anything that's got an active component basically in it and then say it's supportive management. So do we need to support them with CPAP or nasal cannula 02? For this one, it's a tough one, but I would uh with moderate costal recessions and had mild, mild disease increase that. So I think starting the more nasal cannula 02 and then G for feeds is probably the most appropriate thing to do. And if they said severe work of breathing with increased the 02, for example, then I'd say that's the time for noninvasive ventilation. But for this one, these are culinary to, to support their breathing and empty tubes to support their feeling is probably about the right answer. So, as we've already said, bronculitis is a viral infection infecting the lungs in infants under 12 months. It's mainly RSV, but lots of other pathogens as well. That's really compensate. One in three infants, pretty much gets it. 3% of infants admitted hospital in the 1st 12 months of life with bronculitis. That's a big number, right? Like that's 3% and tell that much. But there's a lot of, lot of Children born in the U K every year. And that's a, that's a really, really, really common thing. Classic presentation is an upper respiratory tract infection. So a bit of a sniffle on day one bit of a cough, day one or two, then by day three, you're starting to reduce your feeding a little bit and decided to get a bit of work of breathing day four and five, you reach your peak. So feeding drops, respiratory stress gets worse. And then by day six you're starting to get, you should be on the downward classically the last 10 to 14 days. Um, that's important because it changes clinically what you want to do with them. So, if you see someone day too and they're quite unwell, then you know, they're only going to get worse. Whereas if you're seeing them one day five or six and you think you're moderately unwell, but you don't need any auction and you don't need any feeding support, then they can probably go home. So the timing kind of matters a little bit and just getting that sort of feeling of the presentation in your head. So the feeling for that presentation, which is a little bit slower feeling for croup, which is normally wake up in the middle of night with an absolute bang and strider. Um, the presentation of the viral induced weeds, which is normally over 1 to 2 days rather than the kind of 3 to 5 days. It's just kind of getting those that kind of pattern recognition. And you had a little bit. So just talk about the management bronchial isis. We had asthmatic stairs. We now got a bronchial stick podium because we've got two things to worry about. We've got breathing and we've got feeding. So things which we care about here. So from the breathing perspective, most Children at the bottom of the podium. So it's kind of like a pyramid podium. They need no sports because, and most people in their stats are above 90. So we'll take 90% of bronchiolitis as our baseline. So 92 all other things, but 90% in bronculitis we care about. If their stats are under 90 we'll give them some oxygen, uh the nasal cavity. It, if the stats are over 90 they don't get any option and they don't need it. And if they are then working hard if their CO2 is rising, if they are too breathless to feed, um then normally we'll go somewhere near invasive non invasive ventilation. That's either CPAP which high flow oxygen. So optic flow or high flow oxygen therapy. And there's ongoing trials about which one of those is best, most hospitals in my experience now will go for high flow oxygen therapy first. So it gives you a high flow through the nose. Humidified oxygen gives up to about two per kilo. So if you've got a kilo, baby, give 16 liters through their nose, for example, a humidified oxygen in 100% gives a little bit of pressure, but just a lot of flow where a CPAP give you a specific pressure. That's the difference between them. And CPAP traditionally is for the ones who are a little bit worse and you're on the cusp of needing sort of H D I T, they're really worried and you're really struggling and they're not ventilating the key. We need to make that statement from the other side. From the feeding perspective, they might just need to go little and often. So they might try to get the same amount of feeding like that. They get over 24 hour period feeding for early, but maybe feed them to hourly for half the volume and see if they can tolerate smaller volumes more frequently. You might need to put in a g cheap feed down. Um And if they're really strong and you're still distending their tummy with an N G V, you're taking the work of breathing away from them, work of feeling, story away from them. Then you might need to go on two IV fluids for a short rid of time. And very roughly speaking, if you're needing no breathing support, you're probably not needing any, if you export either. If you're in oxygen, you may well need to think about getting some edgy feeds. And if you're on a noninvasive ventilation, you may well need some IV fluids and it's not, it's not every step is the same. But roughly speaking, you kind of go on both sides and protein at the same time. But the very big overarching news of this is that this viral illness, which needs supportive treatment only. All right. So they're in any way that you see, what management strategy would you come across? All that blood red light is supportive. So, nothing actually not antibiotics, not bronchodilators, not steroids, nothing else that is and active components in some ways in support. You just supported them to get better. Okay. Just to put that into context for you because I think we've caused a lot of sometimes quite a bit of confusion. I'm sure you're kind of right that you're there now. But if you hear wheezing the child, the first question is, how old are they? And roughly speaking again, this is rough if you are under one year, you have bronchiolitis with these pretty much for the sake of your exams. That is your default. Um, if you live in the USA, if you are under two years, you probably have bronchitis. But we don't say that, although sometimes the Chelsea, they say that. So, correct me if I'm wrong. But generally speaking in the UK, if you are under one year, you have bronculitis. If you're over one year, then you probably have viral induced. We's, and at some point that becomes asthma and we talk about it being a viral induced. We'd when it's just with a virus as it does, what it says on the tin, you have a virus, it induces Aweys. You have a wheeze, you then sort of start seeing a picture of a mixed picture where you get a multi trigger weeds where you're kind of sort of, you're starting to see that more atopic. Basically, they're getting with cats called air exertion, um, pollin, you know, multiple other triggers and then they're more on the allergic kind of thing, which is more your aspect kind of spectrum. And then we're talking about diagnosing asthma when you're sort of four or five. And you can show is it some reversibility basically to, to have it some formal sort of reversibility and the multi trigger picture. And, and just to think just for your, just for your brain very quickly, just to think about the differences between those, I think I'm quite a visual person. And if there's any other visual people out there, then, then hopefully this helps. But bronchial is, is thin walled airways, okay. The little pink bits, thin walled airways, loads of information. It's called bronchiolitis. It's got information at the end of it. So loads of information which then creates loads of gunk and loads of mucus. And you can imagine when that mucous sticks together, when you then breathe in, you breathe in, it goes pop. So you get a crackle. All right. So you get crackles and we's here. But we've got really thin walled airways, which bronchodilators are not going to work on contrast that to hear this is completely my brain just making these up, by the way, there's not textbook, but you've got thick walled, like more thick walls, kind of vessels because you're developing muscle in them. They cause bronchospasm in this kind of side of things when you're over a year and you've got more effective beats receptors. I'm sure you've got a little bit of information there, but it's not kind of including your, your, your airway as much as it is when you're very small. And you've got all these beta receptors which are now more effective and are able to improve the situation by by relaxing your smooth muscle, basically. So you've still got wheeze in both of them. But in this one on this side, you've got weeds with crackers which doesn't respond to selfie small and this one on the right side you've got wheeze with no crackles, which probably does respond to be small and that's kind of the way to kind of tease them out for me. We know that you're on this side. If you're under a year, we're going to give supportive treatment, even if they're, even if they're wheezy at the age of 10 months or whatever, we're gonna give supportive treatment to them and say it's not what we can do. We're just gonna support you and they're on this side of it, then they get the, the asthmatic stairs even though they're a violent to squeeze who's at 14 months old. The default is that you'll start on the salbutamol and then you'll see if they have good response to it. Okay? And that, hopefully that just kind of clears up a bit of the clinical management, which I think is kind of the value added in. And I was talking about this and we're going through lots of kind of theoretical kind of questions. Okay. Um Happy any questions on that. Okay. We're gonna for the next. Probably just just I know we started a bit late because because of me probably being well being on a, being on a person that persona non grata list with them with, with your teams. But I'm sorry for the delay in that. But if you're happy to stick with me for, for another 10 ish minutes, then I might just go through some not big topics but just kind of individual questions on a few other top, uh which we can, we can highlight some topics but not talk about the detail. That's okay. Uh Feel free to go obviously if you have to go and I won't be at all offended. Um So Joshua's three weeks old and presents to a and his mom reports that he has been feeding around 50% of usually over the last 24 hours and she has struggled to settle into sleep. She says he has felt quite hot. He denied, she denies any cries or symptoms or DMV. He was born at 37 plus two, had prompted prolongation membranes and but otherwise uneventful pregnancy. He is otherwise well, he cries inconsolably when examined. His heart rate's 175. He's got beautiful two seconds and I can't see what else is behind there for the moment. Sats 98% just as clear abdo, soft nontender. No rush to see in his temperature is 38.3 degrees. What's the most appropriate management for this child? So, do you want to admit him, take blood tests and start antibiotics? If his CRP is raised, all his white cells race going to admit him to the ward start IV. Amoxicillin kept taxing and perform a full septic screen, including a lumbar puncture, going to admit him to the ward. Start Augmentin IV and performer septic screen including an LP to admit him, start, I be careful vaccine, perform a partial septic screen and give a flu bolus would want to send him home with advice, return, if not improving. I have got one answer of be Tory. There's a lot of writing on that page in that. But cool. All right. You seem, you seem pretty confident about that and that's absolutely right. So this is a baby under four weeks old who's got a fever, you don't pass go, you don't collect 200 lbs, you get a full septic screen and you get admitted on IV Amoxil and catch a taxi. Anyone want to comment quickly on why? This is what? So question if they were to six weeks old, what would be your antibiotic choice? Yeah. Kept track saying well done Emmanuel and say kept track saying so why in there under under four weeks we give kept taxing on amoxicillin? Great well done Marina. So Amoxin is for the Listeria coverage. So the evidence is that, so listeria is a cause of meningitis and sepsis in in knee in eights. But it's vanishingly rare after the knee Indians period. So you're giving amoxicillin to cover for Listeria and then not the fully need to know this but keep tracks and causes cholestasis. So when your jaundiced in the, in the first few weeks of life anyway, having cholestasis probably a bad idea. So that's one reason why we give cefotaxime steps okay for tax and democracy on your way forward. And you need to have forceps screen including lumbar puncture, you know, from your fever without focus and guidelines said there's a nice guidelines, the traffic like criteria good to see. And but a child who is younger than three months of age, they need to have a septic screen and performing of some description if they are younger than one month old. And that needs to include a number puncture and we start antibiotics before we have any results back. So they're under one month old or they appear unwell, then they get antibiotics straight away if they are 123 months old. So between the ages of so basically over four weeks of age. So to a maximum three months of age, then you can wait and you can look at their white cell count um in their blood if they are well appearing and they have a fever between one and three months and then make a decision about whether you want to start antibiotics and do a lung punch after that. So that's a nice guideline. It's not quite as clear cut if, if you are between one or three months, but if you are under one month that you have a fever, you must have a full subject screen and have a IV antibiotics. If you are unwell at all, under three months, you must have all those things. If you are well with a fever, 123 months, you can do some blood and look at the white cell count uh and decide from that cut off. This ear infection is four weeks. So it's a neonate. Um So in the first four weeks, good and just be just be aware of the of the traffic lights and what are the red, red flags basically? And you can see that down the bottom there. Red flag is having any fever aged 33 months, a fever over 38 then age 3 to 6 months having a fever of over 39. Hopefully, you already know that a fever of anything after after six months doesn't matter. You can have a fever of 41.6 degrees and have a mild viral infection or a fever of 38.1 have severe meningitis when you're over six months. But when you have a developing immune system, it's far more significant to have a high fever in the first six months of life. Okay. Sally is two years old. She presents to a and E having had a first generalized tonic clonic seizure which lasted for five minutes and self terminated in triage. She is tired but alert and the temperature is 40.1 and she's turkey Kartik. You notice a blanching popular rash on her face, nappy area and on her palms. What is the most likely causative organism of Sally's presentation? Is it Coxsackie virus, Epstein Barr virus Herpes simplex virus, Neisseria meningitis or strip you manually. I've got an eight. I have another. Right. Uh, I've got a third day. Thank you very much. Ok. I agree. So Coxsackie virus causes hand foot and mouth. We're happy with that and, and this child's got a rash on her face and happier and her palms specifically haven't put in the feet there because, and that just makes do it into two easy. It's very rare that you get that you get a lesion on your palms. So basically, it's pretty much only the chicken pox and Coxsackie virus that would, that obviously cause, uh, collisions on your hands. So it's kind of like narrative diagnosis quite a lot is not unusual to have a, to have a, a federal compulsion with Coxsackie virus with them with hand foot and mouth disease E B V as you know, as long more long term it is. And you're normally in your tonsils and it's a course of pussy tonsils. Herpes simplex really causes temperature is so high and normal. You're gonna come across there either in cold sores or an excellent herpetic on Neisseria manager dresses. Obviously, you're expecting a moron. Well, child, if they've got severe meningitis and strep pneumoniae, I again, shouldn't cause a, shouldn't cause this type of rash. They'll normally have to say that it's, um, if they're looking for group a strep anyway, they're going to say it's a sandpaper rash and then for strep pneumoniae, I it's gonna be more either respiratory or, or pneumonias kind of focused. So, just a very quick guide to rashes just in case you get a picture of a rash in your, in your, in your exams. So the question is, was, what's it look like? And let's just talk about very the common ones to start with. So does it look popular? These are popular as they are raised? They are discreet? Okay. So there's no red background, there's not like a widespread red background. There's you could see you could draw a light, you can draw a circle around the individual lesions here, right? And they look like they're, they're lumpy. So popular is lumpy and you can feel it raised and it's discreet. This is a classic hand foot and mouth. So that's one of very relatively few pure papular lesions. Is it macular? So when you run your finger over it, can you not feel it? So you should, it should be flat to the skin if it's macular and you see this is just all if you run your finger over this, you know, you might get a little bit of information but they're not bubbles right there, kind of flat to the skin. Uh and then we think macular stuff. So macular mmr I kind of think so like measles, mumps, rubella are sort of the more macular and rashes measles does end up being macular popular, but quite well. It starts as a macular rash. Maculopapular is basically any other viral rash and it's always blanching. And you can see here that if you run your finger over this, it looks bobbly. So that's those are popular, but it's also got a bit of a red surround. So, you know, you try to get every individual lesion here and try to draw a line around in the air for individual one, you probably won't be able to because it's got a red surround which is connecting multiples of them. So that is a maculopapular rash and that's pretty much most viral infections. Um Just say you have, if you have a rash which is present in certain places, obviously, you can think about whether that's for certain reasons. Slapped cheek would be a classic one, which is part of a virus 19 which is on your cheeks. Clearing vesicular rash is always herpes and so vehicles are small and they're filled with fluid. So that's different, too popular because people are solid. But you can see these ones have got fluid in them, right? So this is not popular, these our physicals and that means that you've got a herpes infection. So that's either gonna be chicken pox where it's gonna be herpes simplex and then that's gonna be better coming. They've got expert there as well. Then one I'll just throw in there quickly is postular, which would be another one which where, where there's obvious puss in there. So they're a bit more yellow, they look a bit more like acne almost and they've got like with the kind of like the white heads and then you're thinking more staff kind of things because they got passed there to kind of think skin infections and then lastly, purpuric and particular. So just happy with the differences between those things. So particular, the top one. So pin pricks under two millimeters and purpura ones that are more like bruising, which are larger than two millimeters. If you've got non blanching rash, obviously, we're thinking about possible severe sepsis. So it can be any sepsis. But meningococcal is the classic one that everyone worries about because it's one of the most rapidly progressive but any, any sepsis can end up in popular formula ones and we call it or a D I C picture. And but more classic things that can a cup in your exam is going to be I T P. And so uh idiopathic thrombocytopenic purpura where you've got a well child who had a recent viral illness and has got some bleeding manifestations, probably so bruising but otherwise completely, well, maybe a bit of a nose, please. HSP you're not Schonlein purpura, which is normally on the buttocks and legs. And that's how you know this, this HSB it's normally also palpable. Those um those purity can run your fingers over it actually feel they're a bit raised. And I think that because they are inflamed. So they are you know, it's an inflammatory kind of condition. So, if you've got inflamed skin, it's going to be slightly raised. And quite often you have arthritis along with that or some kidney involvement. So, UBC nonblanching rash with as well joints, it's probably HSP, nonblanching rash with no swollen joints present everywhere. Possibly I T P very sick child meningitis, X ray, meningococcal sepsis and non specifically on well child for a while with weight loss, possibly leukemia. And it's just interesting to think about why you get bleeding in each one of these miniature local sepsis. You've used up all your clotting factors because you got such leaky capillaries. So you are leaking and you have very inflamed capillaries I T P. You just don't have platelets so you're bleeding but you don't have information. HSB, you've got all your platelets, but you have inflamed capillaries which are leaking into the skin and leukemia cle you don't have your protic, you don't have any platelets down with okay. And on that and, and he's four years old and his parents are concerned that he has developed a rash over the last 24 hours and that's probably 20. He's a runny nose in a mild cough and complains of some abdominal pain on examination. You find a non blanching, widespread rash on his buttocks and mix his heart rate is 1 20 respirator. 25 can't refund to HB is 115 white cells, 7.5 players 173. What's the most likely diagnosis? Yeah, straight in there. So we've already talked about that and we in that, in that discussion. So that's an H S because it's on his buttocks. So it's usually rash on buttocks. You're like, right. HSP. Move on the confirming thing here with the inflammatory cause of that is abdominal pain rather than arthritis. But abdominal pain is very common in HSB, you know, it's not any of the others because we've got some normal bloods and he's otherwise well, OK, quickly I think we might this, I think this is the last one. So Nana Kwame is three years old. He's known to have cerebral palsy and developmental delay. He began convulsing 25 minutes ago and his mother gave him buckle Midazolam. He was given Pr diazePAM by the ambulance 10 minutes ago and he on arrival, he's still fitting what's the most appropriate next antique involvement management. So do you want to give him LORazepam Finito in Peru aldehyde diazePAM on Ortho painting? I've got an A I've got to be, I need one more to want to break the tie or suggest something different, be question mark and a day, right? This is Afinitor one. So remember, and you, your status algorithm is two lots of Benzos. So Benzo Benzo and and then think about something clever. So we can't give another Benzo basically. So he's had already had two Benzos. He's had Midazolam and then he's had diazePAM as well. So we've used our Benzo options. It's got to be a non Benzo. Uh, Finito will be the next appropriate line from this election. Um, finances recently changed, the nice guidelines have recently changed in um uh status to say that you can give Finito in Levitra system. So Keppra or evaporate, um depending on the situation and whether they're on any of those regularly anyway. But classically will be between Finito and, and Keppra, which has been shown to have some of their efficacy uh stopping. Uh it's sort of third line. So Benzo, Benzo and then the third line uh medication if any tone and Keppra are both on that. I think that's a very unfair question unless they're being maintained on Keppra in which case they could fit into it. So that'll be the differentiator in the question for me if they were in both run there. But for this one, etcetera, what if you still can't get a Kanye in when they're seizing? Anyone have an answer to that? I Oh, yeah, exactly. Um So you need to get enough intraosseous needle in and you're not going to hurt them because they're seizing, right. So they're, they're, they're not, they're not conscious. And so I O S are very, very easy to sight, particularly because normally there's not too much fat between the bone and the, on the outside. So you can feel that you're going very easily. It's just that you go through both sides quite often, which is kind of the downside. Um So yeah, you need access, but you've got quite a long time to get that right. So like, you know, if you go down the, if you give that five minutes, you give the first diazePAM first Benzodiazepine, sorry. And then you can get the next one around 15 minutes. Then by the time you're giving, trying 20 to 25 minutes, when you're giving your third line, you've had 20 to 25 minutes to get some access. So you should have something by then and you know, and I owe, if you've, if you've got it is how to give up. Um If you don't have any, any, any kind of option for, for those, then you can think about, you could think about getting another Benzo, but that's kind of more outside the UK management. And this is now actually I did this last year. And so this is now a little bit outdated, but only it's only outdated to say that instead of. So he said Benzo Benzo and then giving Finito in, but it's Ventolin or Valproate or Keppra is what the second line is now. So that's step three. And so just to, just to just to kind of confirm that. So Sebastian is five years old, he's had three epileptic seizures before he presents to Andy with a viral illness. When he starts having a seizure, he was called assess emergently and find he's having a generalized tonic clonic seizure and he's just started, what's the most appropriate, uh which started two minutes ago? What's the most appropriate initial management you want to give back on Midazolam? Immediately apply face mask 02 and check his blood sugar. Give IV LORazepam immediately ask the nurses observations and reassess him in five minutes and says, no refractory. Let way. What do you think? Of course, I've got to be thank you, Isabelle. I could not be one more another beat. All right, thank you. Um And uh I agree. Ok, so we know that we're giving, we need to give something at five minutes. But the key things here are they giving you a timing to say that there's only happened two minutes ago and the thing is give Buckle Midazolam immediately. So that's one of those classic kind of extra things that's like either never always or you know, this should always be given. It's like nothing should always be given like something should never be given. Okay, fair enough like yeah, drugs to Children or whatever, but like mostly can say always or never are incorrect. And then if they put an extra word there, like immediately they're probably trying to make you think that that's not quite right, the right thing to do because they got to cover themselves to justify the question. Uh IV the rest about immediately for the same reason. Uh you're not just gonna ask the message, observations, walk away and come back in five minutes and there's no indication to put in a referral to you. They're way unless you really rest, you rethink the nasal obstruction, their airway and they're not breathing good. And just as F one's or medical students for things to do when you do come across the seizure because everyone is always freaking out. This is just, this is off, off the books because it's not in your exam. But personally, as you want, check the blood sugar, start the timer, call for help. We've done those four things at any level of medicine, but particularly when you're an F one running around the wards and then you've done a safe think and you'll get, you'll get the situation sources. But starting a time at getting the blood sugar and putting 021 r things that always, people always forget to do and you just look at genius if you say to do those when you, as soon as you arrive to a seizure and you've got time, you've got five minutes then soon from when you start the timer to think about whether you need to give any medications or not. So just give everyone a bit of a breath, right? Okay. I'm going to leave it there because I have board you for over two hours now and, and thank you very much for sticking with it. Those who have survived this long. Um, please do ask any questions that you would like to. Um, I hope it's been very useful. I've tried to keep it mainly clinical because I think that's sort of, as I say, that's sort of the value added a little bit. That's not necessarily in the question of banks, um, stuff. I hope it's been a decent overview of some of those topics. Thank you very much for giving up your Thursday evenings and please, please do ask any questions I can be helpful with just before people drop off. Just want to say thank you so much for that talk. It was really, really useful and the best way to show your appreciation, everyone is to fill out the feedback which I've put up and also in the chap. Cool and very, very good luck in your exams. Everyone. I'm sure you will absolutely smash it as you got all these questions, right? So well done and yeah, I'm sure you're going to be absolutely crazy in the exams. Uh, in question, answer to Megan's question. It's not, no, it's probably not worth learning all the normal values. Um, what I do if it's helpful is I, I learned, I learned the neonatal ones and then you already know the the adult ones. So a 12 year old has adult physiology. Um So if you learn the neonatal ones for, for just for heart rate and respiratory rate, that's all you need to name and then you can kind of pro rata rate and just think, does that seem appropriate? Like, so a for example, a neonatal heart rate is between 1 21 60. Uh well hydrated between 1600. So literally you just go neonate 1 20 to 1 60. Preschool Children are 100 to 1 40. School Children are 80 to 1 20. And then that brings you to 12 George which is 6200. It's the same for respirators, 30 to 40 for any in eight and then 25 to 35 20 to 30. And then you're as an adult which is 15 to 20 let's say. So I'd have that in your head just in case they, they're, they're harsh and they don't give you the normal reference range, but you only need to learn the neonate because you already know the adults and then pro rata. So a question on the steroids and profile into sweets. So that this is where. So if you have asked me, you get steroids basically because you have asthma, you've got you, by definition, you probably got an atopic history and you've had a diagnosis and treatment prosperous to give, give steroids, that is the default. And if you have a viral and you squeeze and so the products basically actually win rest effect. But if you have a viral G suite, so you are between the ages of, let's say one and four and you have a wheeze, then you've got to have a good going atopic history and, or multiple kind of episodes of weeks before. And that's for your viral induced these cohorts, if you are diagnosed with us, they're formally then your D forces and you do get steroids. Thank you guys. Uh Right. I'll stick around but any, any other questions, feel free to feel free to ask them. Uh I'll just put my, uh my email actually in the chat as well. If anyone wants to get in touch at all, you're very welcome to about any piece stuff where you have any other questions you are very welcome to just email me and ask me a quick question if I could be useful. Uh repeat seven career stuff for quite a lot of health and safety stuff. Was interesting that you always very welcome to get in touch with me. Thank you so much for the talk. Thanks so much for organizing. Well.