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Hello. Um, my name is T Free and I graduated from the first in a couple of years ago. I'm now working in the UK. So I thought I'd put these presentations together, going to Sure. Um, the way I've been trying to do these presentations is we will go through a couple of really common presentations that I see quite often. Um, and the more you're able to interact, the better it will be. So I'll ask you lots of questions about what more information you'd like. And then we will talk to all of the differentials and, and management processes. Um, in my first walk, I did unwell babies, which I think is coming on to youtube soon the night to Children. So now we're going to see a couple of common teenagers. Um, and again, the disclaimer is, I'm working in the emergency department at the moment and these are all cases I've seen in the last couple of months. So, um, this is my friendly reminder that although Children are not small adults, all of their physiology is a little bit different, all of the principles will stay the same. So you don't necessarily need to know all of the values for normal in kids, but you just need to know that the principles still hold and that you can always fall back on them. OK? I can try screen sharing a different way. One second, one second, I'm just trying to screen share in a slightly more helpful way. Um So I'm going to continue screen sharing like this, this means I can't see the mo comments. So when I ask questions, feel free just to unmute, I don't think there's too many of you in there. Um and give me some answers. Ok. So the first case we're going to talk about is this girl um who comes to the emergency department and this is all this information you get from triage 16 year old girl who's come in short of breath and a bit wheezy. Anybody have any suggestions about things we'd be worried about other questions we'd want to ask um any differentials, any thoughts. Um And if you don't want to unmute, I'm sure we could type in the chat and the organizers can read out the answers that would be fine. Uh Yes, there's a chart of asthma. Yes. Asthma is something we're worried about are worried about asthma in general with someone, someone coming to the emergency department or a particular type of asthma induced by an allerg allergen uh potentially. So we'll be looking at acute asthma which isn't the background shortness of breath that Children will get where you'll need to take preventative inhalers when you're taking regular salbutamol to try and any breathing. So this is the information we get. That first line means up to date with immunizations. No social worker born prematurely at 29 weeks and three days, but has had normal childhood development. Uh scar lives with mom and her two siblings. Her sibling has had a cold and this child has been coughing today. She was a bit more short of breath than normal. Felt she couldn't really breathe has had 10 puffs of the inhaler at home does have a background of a asthma. Um and her obs are relatively stable. Does anybody know which inhaler she might have been using? Um And why 10 puffs is important and bonus points if anybody knows what ac op is, I would be very impressed and any other questions that we might want to ask or anything you'd want to know in the physical exam? Ok. So standard at home treatment for asthma attacks would be 10 puffs of this salbutamol inhaler, which in the UK and most of Europe is blue tends to look like this. Um And the thing that you need to be quite careful about is are they actually using their inhaler correctly because a lot of Children won't be able to administer the inhaler themselves, particularly when they get short of breath and unwell. And even in adults, it's really good practice to try and get Children to use spaces. So it's that big chamber that you're attached to the inhaler and then you can breathe normally and it administers the salbutamol without having to hold their breath. Um She looks quite well when she came in. So we gave her a nebulizer of salbutamol with some ipratropium in it that will help to open up her airways. Um And the bonus question cop was just, it's a combined oral contraceptive pill and it's good to know that there's different terms for it and what to ask for. So acute asthma can be split into mild, moderate, severe asthma. And these are the parameters we've used predominantly to, to review that talking in sentences is a really good sign. Um Not to be able to complete sentences is a little bit more worrying. Um Pef is peak flow is the tube you blow into really hard and it gives you a reading of the force with which the child is able to expire. Um It's really, really helpful if you're not sure about sending somebody home. If their peak flow is over 50% then we're generally doing ok, and they might be able to go home. It just depends how they're coping with that. If it's less than that, I really want the child to be admitted in terms of treatment. We start with salbutamol, as I mentioned, um and would essentially do what's called back to back in a stretch, which means you give 10 puffs of salbutamol and you listen to that chest in an hour. If, after an hour they're still wheezy and they're still working quite hard to breathe. They're using all of their accessory muscles. They're not able to talk in full sentences. It give them some more salbutamol. Listen again in an hour. If the child isn't wh to an hour, you can stretch them to two hours and then maybe give them some more salbutamol. Then three hours, once a child gets to four hours, they're safe to go home. Um, and you can send them home with what's called a weaning plan, which just means that for the first day that they're home every 4 to 6 hours, they should take 10 puffs of salbutamol and then they'll stretch that to once a day over the next week. It's often a good idea if there is any infective or as was mentioned, ear earlier, allergic triggers prednisoLONE to go home with is quite helpful. Um The only thing to be careful about with salbutamol is it can make you become quite tachycardic quite quickly. So I mentioned in this side at the bottom talking obs stable, but tacky on examination. So how often she came into the department relatively stable, but she's now had three rounds of salbutamol. And by the time you go and see her review her, listen to her heart, take her pulse, pulse is going quite far. She was running at about 9899. Um, so I'd be very wary of giving the shot more sout because you don't want to then shut their circulation down. And this is where we'd start considering other medications. Um, and one that's quite good in Children is IV magnesium sulfate. It does mean you need to get a cannula, a child 16. That won't be a problem. But when you do have, you know, 345 year olds getting a cannula in sit, you can be quite difficult. Both technically because the veins are much smaller and also practically because Children don't like being held down, don't like needles, don't like injections and will rip the cannula out. So you have to use it as soon as you put it in. Um which is something we don't always consider, we tend to say, ok, oh If we're doing bloods, which is for the cannula. If the cannula is not going to stay, we should talk about the risk and benefit. Um In this case, it has a cold. Uh You can review the patient if, if they look like they've got a bacterial chest infection, some antibiotics will help but it is more likely to be viral in this age group at this time of year. That is a quick rundown of asthma in terms of exams. This is one of the most important graphs. It's from a website called Teach Me Pediatrics. The Teach Me series is a really good resource for your state exams as well. Um, do we have any questions about asthma? There is nothing on the chart currently. I think we should give them a second if a, if anyone has any questions. Perfect. Oh, hold on. And you can just let me know when to move to the next slide. Yeah, there's still no questions. I think. So. You should, you can continue now. So the next charge you're called to see you actually called to see them in triage because the nurse is a little bit worried. Um You've got a 14 year old girl who doesn't want to talk to you at all. Um And the notes you have a DSP DSP stands for deliberate self poisoning. This is a girl who has either tried self harm with medication or was this an active suicide attempt? And that's something that you need to be able to differentiate between because if a patient is actively suicidal, there are quite different safeguards firstly, in the department to make sure that they're safe. And secondly, whether it's actually safe for them to go home or whether they are considered to be a risk to themselves or to others. So this young girl has just come downstairs and been complaining of tummy pain. Um and mum was a little bit worried mum then found a bottle of paracetamols in her room which she's admitted to taking some, the bottle's empty. Mumm doesn't know how many were in the bottle. Um but the child was only alone for about 30 40 minutes. So what's quite important with a paracetamol overdose is the time in which the tablets were taken. If they were all taken at the same time, it's a slightly different protocol. If what's happened has been what's called a staggered overdose. So they've been taken over the period of an hour, cos your body tends to deal with that. A little bit better. Child has had no prior mental health concerns, no contact with any counseling services, but it has just been noticed to be a little bit more quiet recently. Um What you'll often get in triage notes is things like patient doesn't like school whilst that can be a concern that there's social anxiety or that there might be some other mental health at plate. Most 14 year olds actually don't like the learning part of school. So it's something you need to be a little bit careful about how you interpret. So does anybody know what next things we might want to do for this girl, physically and mentally and to some extent what's more important and which side we should deal with first. Nikole Tesla says uh psychological evaluation. So yes, a psychological evaluation is really important, but most psychological services, psychiatrists, mental health specialists won't see a patient until they're physically stable. This child has taken potentially 100 tablets of paracetamol which can be quite dangerous. So we need to address the physical needs first while safeguarding that her mental health is, are going to get worse. Um, we do need to do a psychological assessment. Yes, but it's not necessarily the first thing we need to do. So, the first thing to do is to take blood ideally an hour to four hours after the time of ingestion, which will include a paracetamol level. Um, there's a service in the UK called talkspace. Every hospital will have their own logins and it will be normally written on the side of the computer somewhere and you can log into it and it'll tell you what critical dosages are. So for paracetamol, if a child's consumed more than 75 mg per kilogram, that's considered over treatment dose. And if, if you think that they've taken enough tablets for that to be the case, which a full bottle even for 14 year old does sound like it. You'd need to do the maths. You need to start on what's called a snap protocol, which is an immediate infusion of NAC, which is N acetylcysteine and it is the antidote for paracetamol poisoning and it is very hepatoprotective. If you can start a patient on NAC within four hours of them, taking paracetamol overdose, there is a virtually zero complication rate. The longer you wait, the more the complications come. Um N infusions are not fun. They make you very nauseous. I normally prescribe them alongside alongside someone that's child, child will be vomiting and physically unwell. It wouldn't be fair to conduct a psychological assessment when a child is in physical distress, pain and being hooked up to medications, they'll need regular bloods, regular observations. Now, on the other hand, what you get more so in younger Children is a three or four year old who has been ill for a couple of days. Mom's been giving her Calpol managed to get into the bottle and has taken a couple of tablespoons that's probably not enough to get to 75 mg per kilo. And that's where you can maybe wait for the four hour paracetamol levels to come back to see if you need to start a patient on that. And if you have older Children, they have taken a notice under that limit if their observations are stable and you believe that the overdose was more required for help than a true suicide attempt. The patient is physically stable and has actually only taken maybe four or five tablets. You can consider doing the psychological assessment first, but it's always really important to get the bloods off as quick as possible. Ok. So this is the snap protocol. Um and every hospital will have a slightly different version, but it is essentially get them in, take blood. If you think it's over a critical value. If you can work it out to milligrams per kilo, that's better and just start them on the treatment until the bloods come back because the longer you wait, the more complications will be involved. Ok. Do we have any questions? Let you go back to the slide on mental health and safeguarding in the emergency department. Um, overdoses treatments, anything like that. And paracetamol is by far and away, the most common overdose. There is nothing yet doctor. Ok. We'll just hold for a minute or any questions about any of the abbreviations on the slides. I've used abbreviations because we use them a lot. And I think it's really helpful if you can start getting used to them while you're in medical school. I appreciate that it's really hard to ask. So NBD would be normal vaginal delivery and Nicole is asking if you could repeat the question. I think. So a doctor is just asking if you guys have any questions about what she has explained right now and feel free to just unmute and talk if that's easier. F OK, so the next child you're called to see is a 15 year old boy who's been brought in by his friend with quite severe abdo pain. He's had paracetamol and ibuprofen, he's still in a lot of pain. Um So there's a lot of differentials with abdominal pain. Um and that's not enough information to go on. So we do some taking and some physical exam. He says the pain started and he was just out playing in the park. Um which is good because it gives us an idea that it's not related to food. It's not when he's eating something, it's not related to straining. It's not related to diarrhea, some nausea, but no vomiting is reassuring in terms of pancreatitis and things like that kind of diffused over the lower part of his body. His abdomen is soft and nontender. So we're not worried about a surgical abdomen. We're not worried about appendicitis. He's a diffuse discomfort but there's no guarding, no rebound. Um, he reports he is sexually active. He reports he has intermittent alcohol consumption but no other drugs but no medical conditions when we fit and well being a bit shifty at his friends there. Um, but it is happy for his friend to stay. Do you have any questions? Suggestions, thoughts, any other examinations you think it would be important to do aside from just looking at his tummy and there's a chart for ultrasound, ultrasound of the abdomen. Uh could be helpful. But what are you looking for? You need to have a differential in mind before you start requesting tasks. Also. Again, it's not something I'd expect you to know. But getting a sonographer to do an ultrasound tends to happen 9 to 5 Monday to Friday. Um You'd be quite hard pressed to get a formal ultrasound out of hours and most Ed registers and Ed doctors will be qualified in fast scans or we'll be able to see if there's free fluid, but we wouldn't be able to do a full abdominal study. And also we don't know what we're asking. And also we got the location on ultrasound. She says appendicitis. So this, this child, well, they're walking, they're talking, their observations are normal. They don't have a fever. There's no vomiting. Their abdomen is soft, no rebound tenderness. It's not a typical history of abdominal pain starting in the epigastric region radiating to the right lower quadrant. So it's quite unlikely to be appendicitis. Um And also ultrasound won't necessarily rule it in or out. It's not sensitive enough to diagnose on. Also, doctor, there's a question for you uh from Sheila, what are the findings on physical examination during palpation? Any tenderness or which quadrant is particularly affected? So, I've said his abdomen is soft, nontender. He's got diffuse discomfort a little bit more in his lower abdomen. But you've got no classic Murphys, no classic rebound. He's not got a fever sent bloods off. They haven't come back yet. Oh, there's a chart for uti potentially uh uti in a boy of this age. I'd be quite worried about. Um UTI S in boys tend to start, tend to happen kind of under the age of one year. And then if there's some underlying condition, if this is a 15 year old girl, yeah, UTI would sound reasonable. Um But he's not got any urinary symptoms, no frequency, no burning, no struggling to we no struggling to maintain the stream. Um So the one thing that's really, really important to do, particularly in babies and boys at the age of puberty. So I'd say anywhere between 10 and 16 is a testicular exam. Um because this is quite often how testicular torsion can present and testicular torsion is a surgical emergency. Um And the child will, if there is to she likely need to go to theater. So the important thing when you do it take your exam is to always have a chaperone with you. So you don't have it alone. Always make sure you wear gloves, always make sure you explain what you're doing. Um And even if a teenage boy has testicular pain, they will tend not to start with that information. So you ask friends to step outside, you do a test, take your exam and you notice that there's a high riding testicle in a horizontal line and the patient mentions he has undescended testes as a child. So this is essentially testicular torsion until proven otherwise. Um This is a really helpful graph. I found particularly the right hand two columns looking at torsion and then torsion of the appendix. Um because it's quite difficult to tell the difference between the two of them. And quite often urology will come and do a point of care. Ultrasound of the scrotum, not of the abdomen. Um The chromic reflex is absent in torsion, but to be honest, eliciting the premier reflex is incredibly difficult and that's not a sign I'd be confident to rely upon what's really important is the history of the pain. If there's severe sudden onset pain, it's more likely to be torsion if there's sudden onset pain. But actually, if the boy is sitting with his legs wide open, he's a lot more comfortable, it's more likely to be torsion of the appendix of the testes which while still painful and still dangerous is less of a surgical emergency. And epidermitis, you need to present with a fever essentially or some kind of other infective signs. So, either white blood cells in your urine or urinary symptoms or elevated inflammatory markers in your blood. In terms of what would happen from an ed perspective, it's nil by mouth pre op workup. So an ecg bloods and making sure the patient is relatively well pain controlled, which there's really lots of IV morphine at this stage and they tend to go to theater within a couple of hours. It's one of the few times that urology will take a patient and go if you can see that one testicle is completely vertical and it's completely horizontal, they probably won't even do an ultrasound. Um They'll just go straight for surgical exploration. Um I thought this was quite an important one because although everybody knows that testicular torsion is a surgical emergency, we often forget that it presents with just diffuse abdominal pain. Um because if someone comes up to you and says, oh, my testicles really hurt you kind of know where you're going because it's very, very easy, especially, you know, being a woman and you've got a young teenage boy, they don't want a testicular exam. You don't think to do a testicular exam, but it's really, really dangerous if missed. Um, so yes. Any questions on torsion. Oh, anything else, any other differentials you'd like to discuss for abdominal pain? It could be a whole series by itself. Uh, someone was asking what about autoimmune disease for abdominal pain? Like something like celiac disease. It could be, definitely, could be. I think a, that's not something I'd be worried about in the emergency department. Um, I tell them to go back to their GP. Also, you need to ask a bit more for history about stools. Has there been any change in stools? Any change in volume? Any other symptoms, fatigue change in diet, things like that? So, it's not quite looking. Um, like it could be that also. It'd be a bit weird for a sudden onset pain in an autoimmune disorder with no preceding symptoms. Is there anymore? Uh, no, I didn't hear that. We're gonna go on into our last place of the day. A 13 year old girl who comes in with a personal problem. She doesn't want to tell triage what the issue is. Um, she's got her mum with her and she is absolutely mortified to be in the emergency department. She does not want to talk to you. She doesn't want to be here and she's essentially refusing to talk to her mum as well. Any comments at this stage. So you get them both in an examination room and the child's still just not talking to you in any way, shape or form. There's a step, sorry, there's a comment for pregnancy or any sex related issues can be. So, so you, you come in and mum says she's noticed that her daughter's had really smelly discharge, vaginal discharge for the last couple of days. She doesn't want to talk to her mum about it. She's very upset that her mum's brought her into the emergency department. Mum's quite worried because she doesn't really know what's going on and whilst the child seems well seems not to be concerned by this. Um but it's quite a strong smell. Um Her last period 10 days ago reports she's still a virgin. So very unlikely that she'd be pregnant. I'd still do a pregnancy test. She's not got any fever. She's not systemically unwell. Her observations are normal. She's walking independently moving all four limbs now, vi neurology, which is what I describe as a well child. Um Any comments, questions, thoughts, how do we feel about still going down the STD route that was mentioned in pregnancy? Uh There's a comment for like doubt she is a version or sorry, sorry before you continue. There's one more for any itching. Ok. So no itching. Um but thinking of thrush is quite a good thought process. Thrush tends to present with thick white discharge as opposed to smelly discharge. Um, but that's a really good thought in terms of the questions about her sexual history. I think the golden rule of medicine is always listen to your patients, but don't always believe them. If you do a bit more digging, she'll probably say something like, oh, I can't be pregnant because I've never actually had sex, But of course, I've done everything else. So you're immediately all over thinking about ST is because actually teenagers who engage in sexual activities and will not have penetrative sex are a much, much higher risk of STD S because they won't use a condom. So yes, while she's technically correct that she's not had penetrative sex, she's still quite high risk for an STD. Also doctor, there's a question. Can we perform physical examination in private instead of with mom? You can, um, you need to be a little bit careful about how you do it and you just need to make sure that mum doesn't feel shot out. So, what I normally do is I will do my full history and physical exam with mum there and especially in this case where the kid is absolutely refusing to talk to you. And the only history you're getting is from mum. And then I'd say ok, because you're over the age of 10. Um, it's, it's good practice to ask your mum to step outside and we're just gonna continue to have a little bit of a chat and then do the whole thing again. Um, because that way you get mom's opinion because mom does also know her daughter but her daughter is more likely to admit to things. So on examination, her abdomen is soft and nontender. She's breathing well, talking in full sentences, no fever, no obvious injuries. Um, there's quite a significant smell, um, but she reports no itching, no burning. She says that the discharge is a little bit like watery and brown, kind of like the end of her period. But her period finished five days ago. So LMP is last menstrual period started 10 days ago, finished kind of four or five days ago. Was her normal period. No concerns. Um So she's not had any new sexual partners in the last four months and thinks she's low risk for an STD. You. I would still recommend she books in for an STD test, but that's not something that we'd offer in the emergency department in the UK. There's a postal service where they'll send you swabs and a fingerprint and you can post everything back. So it's um, really confidential, really easy and I'd always recommend everyone does it, any other ideas about what could be going on. So we've, we've said probably not pregnancy, probably not an STD given her history. She's systemically. Well, she's not got any pelvic pain. She's not had any other issues. It's, it's just this discharge. It's quite a lot, quite brown, quite smelly. We'll take some swabs to see if she does have an STD, but it, you wouldn't necessarily give her any antibiotics. And the key is in her period, finished four or five days ago. So, at this point, I've got a normal physical exam. A well child, significantly distressing kind of discharge. I'd, I'd look at doing a speculum exam. Um, a good top tip, not in a 13 year old, but maybe in a younger child is the smaller size of speculum is still quite large. It would probably fit um for a 13 year old would be uncomfortable but not unbearable for smaller Children, particularly if you're concerned about foreign bodies or sexual abuse in toddlers, the nasal speculums that they use in ent can work quite well. Um So again, similar to a test, a exam, I make sure I'm in a room with cut and privacy, make sure there's a chaperone there, explain what I'm doing. Um If you can use a metal speculum, make sure it's heated up, make sure there's a little bit of lubricant on the outside, slow, gentle pressure. Um There are lots of ways to make a speculum less painful. I strongly recommend using all of them. Um So you do your speculum exam and you find a tampon that's been in there for four days, you can see the tip of the tampon. So you get a pair of forceps and essentially to pull the tampon out. Um, it's more common that patients pretend saying, I think there's a tampon stuck in there. I forgot to take one out. I was really busy. I can feel the string, but I can't quite get it out. I'm really scared that tends to be in older women. Um, I've only ever seen a couple of teenagers present like that if the child is well, they've had normal blood, no fever, no other symptoms. You can just take the tampon out, dispose of that discharge the patient home with healthy advice on making sure they remember to take tampons out, making sure that they use good hand hygiene, wash your hands before you change your tampon as well as afterwards. And that if the discharge doesn't stop in the next couple of days or she develops any fevers, fatigue flu like symptoms, then it's really important that she comes back to the emergency department because at that point, she might need antibiotics. If she'd left it a little bit longer, patients can come in essentially septic from pelvic inflammatory disease. And at that point, you need to be admitted to have antibiotics, but you don't necessarily need to give prophylactic antibiotics for a retained tampon. Ok. If, if there's any suggestion that they could have left the tampon in, it's, it's less painful if you can encourage them to go to the bathroom, bear down with a lot of pressure and try and remove it themselves. Um, a because it's an intimate procedure that it's more comfortable if they do themselves. And b avoiding a speculum in a teenager is always a better option because they can be quite distressing and quite painful. Ok. Any questions. Uh, doctor, I have one question. Uh, can a tampon that's been stuck for a coup for like four days, like in this case, can it lead to be a source of infection? Yes, it definitely can. So, should we examine her blood after we removed the tampon or something like that? To check for infections if she's systemically? Well, she's got no pelvic pain, no fatigue, no fevers. Then I wouldn't, I wouldn't necessarily, um, because we just avoid doing blood tests in kids in an adult. Maybe I'd be a bit more likely to say, mm. I'm not 100% sure we'll just get some blood but the bloods will take a couple of hours to come back. And actually, if she's, well, her inflammatory markers will be slightly raised. But would you necessarily treat her just for raise inflammatory markers with antibiotics if she's not actually unwell? So it's, you know, if you're, if you're a little bit worried about her and you think, you know, I think she does have a bit of fever, she's been a bit more tired, a bit more, run down then. Yeah. But if she's, well, there's actually no need, it's just really really good advice to go home with that. If she develops any of those symptoms, it's really important she comes back for a blood test because the vast majority of these patients won't need antibiotics. All right. Thank you so much. Ok. So that's the end of my case.