1 / 34

Paediatric Emergencies David Smith

Paediatric Emergencies David Smith. Or.....Children who present to emergency departments with a history suspiciously similar to past paper questions. Previous MEQ’s. Pyloric stenosis Acute appendicitis Intusseception Henoch-Schonlein purpura Osteomyelitis Painful knee Febrile convulsions

shing
Download Presentation

Paediatric Emergencies David Smith

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. Paediatric EmergenciesDavid Smith

  2. Or.....Children who present to emergency departments with a history suspiciously similar to past paper questions....

  3. Previous MEQ’s • Pyloric stenosis • Acute appendicitis • Intusseception • Henoch-Schonlein purpura • Osteomyelitis • Painful knee • Febrile convulsions • Vomiting and fever • Cyanotic heart lesion

  4. Previous EMQ’s • Vomiting in infancy • Respiratory problems in childhood • Abdominal pain in childhood

  5. Abdominal Pain http://parenting.st701.com/filestore/resize_article_image11274781758.jpg

  6. Abdominal pain- differential Miall, Rudolf & Levene. Paediatrics at a Glance 1st Edition (2003)

  7. Acute appendicitis • Most common cause of acute abdomen in children • Usually older than 5 • History • Anorexia, reluctance to move, sore to cough. • May be vomiting and low grade fever. • Increasing pain in right lower quadrant • Exam • Tachycarida, lying still, shallow breaths, guarding • Can they sit forwards unsupported or hop? • Psoas, Rovsing, Obturator, Dunphy, Heel drop, McBurney’s

  8. Acute appendicitis • Investigations • Leucocytosis , raised CRP, USS, CT if diagnosis unclear, urinalysis • Significant risk of perforation • Perforation signs • Patients looks ill! (or more ill than before) • Rigid abdomen, severe pain, high fever, localised tenderness, vomiting, percussion pain, and decreased bowel sounds. • Management • Appendectomy, IV Antibiotics

  9. Intussusception • Telescoping of the bowel wall • Usually terminal ileum into caecum • Most common in males aged 3-12 months • Causing obstruction of the bowel • History • Episodic screaming and pallor, well between episodes • Vomiting, lethary/irritability • Passage of blood and mucous in stool (redcurrent jelly) • occurs in 75% as late sign http://www.smartdraw.com/examples/view/intussusception+of+the+gastrointestinal+system/

  10. Intussusception • Exam • Dehydration, palpable ‘sausage-shaped’ mass • Blood on rectal exam • Investigations • AxR , USS, Diagnostic enema......CT? • Complications • Intestinal ischaemia, Necrosis, Perforation, (death) • Treatment • Air enema, laparotomy

  11. Henoch-Schonlein Purpura • Small vessel IgA vasculitis. • Triad of Arthritis, Colicky abdominal pain, Purpuric rash (non-blanching) • Arthritis of large joints, short lived • Purpuric rash over buttocks and lower legs • Renal – dipstick haematuria and proteinuria in 50% • Usually males, aged 3-15, • Recent history of URTI

  12. Henoch-Schonlein Purpura http://dermatlas.med.jhmi.edu/derm/display.cfm?imageid=-1353783694

  13. Henoch-Schonlein Purpura • Investigations • Urinalysis (dipstick), 24 hour urine for protein • FBC’s, U&E’s, Serum IgA (may be elevated) • Coagulation studies (normal in HSP) • Biopsy – skin, renal • Management • Usually resolves spontaneously in 4-6 weeks • Symptomatic Rx = NSAID’s +/- Corticosteroids • Follow up for 6 months with urinalysis and BP monitoring

  14. Vomiting http://www.break.com/pictures/mmm...vomit659527.html

  15. Pyloric Stenosis • Hypertrophy of the pylorus muscle • History • Vomiting – projectile starting in 4-6th week of life • Within an hour of feeding • Vomiting is non-bilious • Child always hungry • Most common in male infants • May be history of constipation http://pedsurg.ucsf.edu/media/85927/img_main.gif

  16. Pyloric Stenosis • Exam • Dehydration, visible peristalsis, weight loss, palpable olive-shaped mass in URQ • Investigations • USS • ABG – metabolic alkalosis • Bloods – low Cl-, K+ , Na+ , • Management • Rehydration and correction of electrolytes • Surgery = Ramsteidt’s Pyloromyotomy

  17. Other causes of vomiting • GORD • Bowel obstruction • Duodenal atrasia (Down’s) • Hirshprung’s disease • Meconium Ileus (CF) • Gastroenteritis • Sepsis • Always consider UTI or early meningitis

  18. Dehydration Miall, Rudolf & Levene. Paediatrics at a Glance 1st Edition (2003)

  19. Dehydration - signs

  20. Febrile Convulsions http://xkcd.com/901/

  21. The Fitting Child Miall, Rudolf & Levene. Paediatrics at a Glance 1st Edition (2003)

  22. Febrile Convulsions (seizures) • Convulsions triggered by fever (>39o) • Simple (75%) • Single seizure lasting <15 minutes • Neurologically normal before and after • Normal neurodevelopment • Seizure not due to CNS infection • Complex (25%). As for simple but: • Seizure is focal or lasts > 15 mins • Seizures in close succession (2 in 24 hours) • Status epilepticus

  23. Febrile Convulsions (seizures) • Patient young - usually 3-5 years • Often family history of febrile seizures • Diagnosis is clinical • Seizure associated with fever • Investigations • FBC, U&E’s, Glucose, blood culture, Blood and Urine toxicology , Anticonvulsant levels, ABG • Brain imaging CT/MRI • EEG

  24. Seizure / Status management Airway High Flow Oxygen Check Glucose Lorazepam IV/IO Rectal Diazepam Or Buccal Midazolam If IV access established give 2nd dose lorazepam (see left) Lorazepam IV/IO Paraldehyde PR Phenytoin IV/IO Or Phenobarbital Call anaesthetist - ITU

  25. Temperature management • Reduce temperature • Undress child • Sponge with tepid water • Antipyretics = ibuprofen or paracetamol • Future advice to parents • Give antipyretics early in any febrile illness • Reduce temperature and plenty of fluids • 1/3 of children who experience a single simple febrile seizure will have another.

  26. Finally...A quick case 1 This is an entirely fictional case. Any resemblance to actual real people or cases encountered in past papers is entirely coincidental.

  27. A sick neonate • You are the Paeds FY1 in a DGH • Called to see sick male infant • 28 hrs old born by SVD • Not feeding well (bottle fed) • Lethargic • Mottled appearance • Midwife ‘thinks he is dusky’ • Apyrexial • RR = 45 http://blog.dearbornschools.org/renkom//

  28. Further observations • What further obs would you perform • Nurse has already take O2Sats • HR • BP • Pulses • Temperature? Apyrexial • Blood glucose?

  29. Further investigations • What further investigations would you do? • Blood gasses • CxR • ECHO • Bloods (FBC, CRP, Culture)

  30. Further investigations • Describe an investigation to the parents and explain the reason for it • Can you?

  31. Investigation results • CRP <6 (<10) • WCC 11.6 (9-30) • Hb 17.5 (14-20) • Platelets 224 (100-300) • Sats now 74% on air – not improving with facial oxygen

  32. Diagnosis? • Ductal dependant cyanotic heart disease • Reason for deterioration? • Closure of ductus • Further referral • Cardiology (or NICU) • Reasons to give parents for transfer • More intensive care – not available in general paeds unit • More investigation and management options • Specialist centre = specialist personnel

  33. References • BMA best practice • Oxford handbook of paediatrics 1st edition • Oxford handbook clinical specialties • Paediatrics at a glance • Oxford handbook clinical medicine 8th Ed • http://emedicine.medscape.com

  34. http://www.explosm.net/db/files/Comics/Rob/drbaby3.png

More Related