Aims & objectives Organ Emergency Respiratory Croup Bronchiolitis Viral induced wheeze Asthma exacerbation Epiglottitis Neurology Seizures Pyloric stenosis Gastroenterology and Intussusception surgery ALL Haematology Sickle cell crisis Meningitis Infection Sepsis Anaphylaxis Other Kawasaki disease 2
Case-based discussion: 1 History A 7-year-old child is rushed into the emergency department by his mother. He is breathing heavily and struggling to complete sentences in one breath. He appears drowsy and confused. The patient has a history of asthma. On examination, you note intercostal recessions and a generalized wheeze. His PEFR is 39% of his baseline. Observations HR 126, RR 35, SpO2 89%, Temp 38.1 (HR: 70-110) (RR: 20-25) 3
Question: 1 4
Case-based discussion: 1 History A 7-year-old child is rushed into the emergency department by his mother. He is breathing heavily and struggling to complete sentences in one breath. He appears drowsy and confused. The patient has a history of asthma. On examination, you note intercostal recessions and a generalized wheeze. His PEFR is 39% of his baseline. Observations HR 126, RR 35, SpO2 89%, Temp 38.1 (HR: 70-110) (RR: 20-25) 5
Introduction: Asthma Exacerbation Definition: airway bronchospasm and inflammation resulting in airway obstruction Epidemiology Asthma affects 11.6% children aged 6-7 (NICE) • 60,000 hospital admissions per year in the UK • Risk factors Viral infection • Inhaled allergens • Exercise • Emotion • NSAIDs • 6
Pathophysiology: Asthma Exacerbation Inflammatory response is driven by T-helper type 2 (Th2-cells) 1. Bronchial inflammation and bronchospasm • Terminal bronchioles 2. Bronchial obstruction • Increased mucous production and mucosal oedema • Bronchospasm • Smooth muscle hypertrophy 3. Bronchial hyperresponsiveness 7
Clinical features Symptoms Signs Evidence of trigger Respiratory distress Breathlessness Wheeze Exhaustion Reduced feeding Reduced GCS 8
Moderate Severe Life-threatening SpO2 ≥ 92% SpO2 < 92% SpO2 < 92% and any of: No features of severe asthma Too breathless to talk or feed PEFR < 33% (aged >5) Aged 2-5 Silent chest HR > 140 • RR > 40 • Aged > 5 Poor respiratory effort HR > 125 • RR > 30 • PEFR 33-50% • Use of accessory neck muscles Agitation Exhaustion Hypotension Cyanosis Confusion 9
Investigations: Asthma Exacerbation (1) Bedside PEFR • Moderate: > 50% • Severe: 33-50% • Life-threatening: < 33% • Bloods Blood gas: evidence of respiratory failure (type 1 • or type 2) Inflammatory markers: raised if there is an • infective trigger Imaging CXR: hyperexpansion and/or evidence of infection • 10
Question: 2 History A 7-year-old child is rushed into the emergency department by his mother. He is breathing heavily and struggling to complete sentences in one breath. The patient has a history of asthma. On examination, you note intercostal recessions and a generalized wheeze. His PEFR is 39% of his baseline. Observations HR 126, RR 40, SpO2 89%, Temp 38.1 (HR: 70-110) (RR: 18-30) 11
Question: 3 History A 7-year-old child is rushed into the emergency department by his mother. He is breathing heavily and struggling to complete sentences in one breath. The patient has a history of asthma. On examination, you note intercostal recessions and a generalized wheeze. His PEFR is 39% of his baseline. Observations HR 126, RR 40, SpO2 89%, Temp 38.1 (HR: 70-110) (RR: 18-30) 12
Management: Asthma Exacerbation Oxygen: aim for SpO2 ≥ 94% Bronchodilators: inhaled or nebulised if hypoxic Salbutamol +/- Ipratropium • BURST/back to back: 3 salbutamol nebulisers • and 1 ipratropium nebulsier Corticosteroid Prednisolone PO • Hydrocortisone IV if unable to tolerate • IV bronchodilation MgSO4, Salbutamol, Aminophylline • Intubation and ventilation 13
Differential diagnosis: Respiratory distress Bronchiolitis Croup Viral induced Asthma Pneumonia wheeze exacerbation < 1 year < 3 years < 5 years > 5 years Any age • • • • • 9 day illness Barking cough Wheeze Wheeze Productive • • • • RSV Parainfluenza Generally well Symptomatic cough • virus in between between High fever • episodes episodes Crepitations If the child requires admission: • Bloods including capillary blood gas • CXR 14
Case-based discussion: 2 History A 6-week-old male presents with multiple episodes of projectile vomiting after feeding. You note a visible olive shaped mass in the abdomen. He has had 2 wet nappies in the last 24 hours. When observing him being fed in the emergency department, he vomits 10 minutes later. He has mottled skin and a capillary refill time of 3 seconds. Observations HR 170, RR 55, SpO2 95%, Temp 37.2 (HR 110-160) (RR 30-60) 15
Question: 4 16
Case-based discussion: 2 History A 6-week-old male presents with multiple episodes of projectile vomiting after feeding. You note a visible olive shaped mass in the abdomen. He has had 2 wet nappies in the last 24 hours. When observing him being fed in the emergency department, he vomits 10 minutes later. He has mottled skin and a capillary refill time of 3 seconds. Observations HR 170, RR 55, SpO2 95%, Temp 37.2 (HR 110-160) (RR 30-60) 17
Introduction: Pyloric Stenosis Definition: hypertrophy of the pyloric smooth muscle of the stomach Epidemiology 2-4 per 1000 live births • More common in males • Risk factors Age: 2-6 weeks of age • Male: 4x more common • First born • Family history • (2) Caucasian • (Maternal macrolides) • 18
HCl K+ Na+ (3) 19
Introduction: Pyloric Stenosis Metabolic alkalosis Loss of gastric acid (HCl) • Hypochloraemia Loss of chloride ions (HCl) • Hypokalaemia Loss of potassium ions • Hypovolaemia activates the renin-angiotensin-aldosterone • system à sodium reabsorption and potassium excretion (2) 20
Clinical features Symptoms Signs Projectile non-bilious vomiting post- Evidence of dehydration feed • Capillary refill time > 2s • Mottled skin • Dry mucous membranes • Sunken fontanelle Reduced wet and dirty nappies Visible peristalsis Olive shaped mass in the upper Poor weight gain abdomen 21
Clinical features (4) 22
Investigations: Pyloric stenosis Bedside Test feed: observe for vomit • Glucose • Bloods Capillary blood gas: pH, Na, K, Cl, HCO 3 , lactate • Hypochloraemic, hypokalaemic, metabolic alkalosis • Urea & electrolytes • Imaging Abdominal USS: sensitivity 99% • >3mm thickness of the pyloric muscle • (5) 23
Management: Pyloric stenosis Management Supportive • NBM and NG tube decompression: • stomach decompression IV fluids: rehydration and • replacement of electrolytes Surgical • Ramstedt pyloromyotomy: incision • of the muscles of the pylorus (6) 25
Case-based discussion: 3 History A 7-month-old child presents to the emergency department with his mother. The child is lethargic and floppy. He is visibly very pale and has a distended abdomen. The mother reports the child has been vomiting and has passed red coloured stool on a few occasions. You note him drawing up his legs to his abdomen and start crying. Observations (7) HR 190, RR 66, SpO2 94%, Temp 37.5 (HR 110-160) (RR 30-60) 26
Question: 5 27
Case-based discussion: 3 History A 7-month-old child presents to the emergency department with his mother. The child is lethargic and floppy. He is visibly very pale and has a distended abdomen. The mother reports the child has been vomiting and has passed red coloured stool on a few occasions. You note him drawing up his legs to his abdomen and start crying. Observations (7) HR 190, RR 66, SpO2 94%, Temp 37.5 (HR 110-160) (RR 30-60) 28
Introduction: Intussusception Definition: telescoping of a proximal segment of bowel into a distal segment Epidemiology Rare: 30-100,000 infants • Most common in males • Aetiology Lead-point hypothesis • Risk factors Age: 6-18 months • Viral infection • Henoch-Schonlein purpura • Lymphoma • 29
Pathophysiology: Intussusception • Viral infection: hyperplasia of Peyer’s patches • Henoch-Schonlein purpura: submucosal haematoma • Lymphoma (8) 30
Clinical features Symptoms Signs Colicky abdominal pain Abdominal mass Episodic crying and agitation • Drawing knees up to the chest • Bilious vomit Abdominal distention Bloodstained stool: ‘redcurrant’ jelly Hypotension and tachycardia 31
Clinical features (7) 32
Question: 6 33
Investigations: Intussusception Bedside Glucose • Bloods Capillary blood gas: raised lactate with • metabolic acidosis if bowel ischaemia FBC: anaemia • Urea and electrolytes: dehydration and AKI • Imaging Abdominal USS: diagnostic investigation • Contrast enema: diagnostic and therapeutic • (9) 34
Management: Intussusception First line: • Resuscitation: ABCDE • IV fluids and blood products may be needed • IV antibiotics: prevent abdominal sepsis • Radiological reduction: air or contrast Second-line: • Surgery: resection may be needed 35
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