Paediatric Emergencies

Paediatric Emergency Medicine

1. Paediatric emergencies Misbah Mohammad EM/PEM Consultant PED Clinical Lead

2. Approaching children when vulnerable Strangers Strange environment Rapport building Play Distraction Check with PED Nurses Listen to parent/ carer concerns

3. History taking Source of history Witness of the story – nursery/school notes Delayed or timely presentation – timeline – reattendance Professional curiosity – exploring – non-judgemental Birth History Vaccination History Social History including safeguarding history

4. EXAMINATIOn Top-to-Toe exam without clothes in infants & toddlers with injuries HEENT Chest – including WOB & noise like grunting CVS – Cap refill time – peripheral vs central – cold vs warm Innovative exam techniques

5. Common presentations Fever including Croup Wheeze, DIB Injuries ***NEEDLE in a HAYSTACK – SEPSIS & SAFEGUARDING CONCERN

6. FEVER URTI (including Tonsillitis) &/or EAR INFECTION – Abx or no Abx Chest Infection – CXR or no CXR UTI – Culture or no Culture; Abx or no Abx Meningitis/Meningococcal Sepsis/Encephalitis Septic arthritis, discitis *** KAWASAKI DISEASE *** PIMS-TS Fever in under 5s: assessment and initial management  NICE guideline [NG143] Published: 07 November 2019

7. NICE TRAFFIC LIGHT THINK SEPSIS – Escalation vs De-escalation – Consider Resus based care – Senior Review – Team based care – Early involvement of Paeds team in sick patient’s care

8. Meningococcal sepsis/Meningitis PETECHIAE IN CHILDREN – THE PIC STUDY Lancet APRIL 2020

9. Non-blanching rash

10. Henoch- Schonlein purpura

11. KAWASAKI Disease

12. PIMS – TS Paediatric Multisystem Inflammatory Syndrome temporally associated with SARS-CoV-2 severe inflammation & shock some clinical similarities to Kawasaki shock & toxic shock Cardiac Manifestations: Pancarditis may include bi-ventricular impairment, mitral/ tricuspid valve regurgitation, diastolic dysfunction, pericardial effusion, coronary artery dilatation / aneurysm Clinical course unpredictable with rapid deterioration observed in some

13. FEBRILE SEIZURE Aged 6 months to 6 years Simple FS - isolated, generalized, tonic- clonic seizures lasting < 15 mins, do not recur within 24 hrs or within the same febrile illness, with complete recovery within 1 hour Complex febrile seizures  have one or more of: partial (focal) seizure; duration > 15 mins; recurrence within 24 hrs or within the same febrile illness; or incomplete recovery within 1 hour

14. Bronchiolitis – RSV Wheeze vs Stridor vs Grunting Inhaler vs Nebs Salbutamol vs Atrovent Symptomatic & feeding support Nasal saline +/- suction +/- Oxygen – Consider HFNO – Escalation

15. Bronchiolitis – RSV

16. Bronchiolitis – RSV

17. Discharge CRITeria for Bronchiolitis Oxygen Saturations maintained in air O 2 Sats >94%. Is clinically stable, taking adequate oral fluids and has maintained oxygen saturation over 92% in air for 4 hours, including a period of sleep.

18. Viral wheeze/ASTHMA Toddler (> 1 yr ) to pre-school children (under 5 yrs ) to school children > 5 yrs Inhalers with spacer device – treatment of choice Life threatening – Nebs Salbutamol +/- Atrovent Steroids Reassess & Paeds referral (PAU if PEWS < 3)

19. BTS classification of wheeze/asthma

20. BTS management – first line of treatment

21. BTS MANAGEMENT – second line of treatment

22. BTS – Asthma/Wheeze under 2 years

23. DKA DKA Calculator BSPED DKA Flowchart

24. AFEBRILE SEIZURE/EPILESPY A to E Assessment Contemporaneous management DON’T FORGET ‘G’ First fit Known epileptic Difficult fitter – advanced care plan

25. INJURIES MOI – think major trauma – senior involve +/- Paeds trauma team activation Presentation – timely or delayed Professional curiosity Patient safety – Resus or Cubicle Primary, secondary & tertiary victims in polytrauma Paeds (unwell) Debrief

26. INJURIES – HEAD Injuries NICE Head Injury guidance to follow MOI Scary sight for parents – LOC, Drowsy, Irregular Breathing, Floppy, Palor Usually come around in few minutes – observation

27. INJURIES – Limb INjuries Long Bone fractures Age-appropriate injuries (NAI vs AI) MOI – corroboration Supracondylar Fractures Femur/TF Fractures in infants Toddler fracture vs Trampoline fracture Limping child – traumatic vs atraumatic

28. Non-Accidental injuries Story – MOI, TOI (any delay – reason) Witness Corroborate – story vs injury sustained Low threshold Professional curiosity Pattern – bruising - Body Mapping

29. Sick children Scary Team based-approach led by senior Paeds team involvement Systematic approach – A to E including WETFLAG – APLS protocol Respiratory vs Cardiac arrest Rate limiting steps – IV/IO access History, Examination & Differentials Planning for further investigation & management – SICK KIDS referral

30. SICK neonates & infants Unwell – SEPSIS Check BM - hypoglycemia common in sick babies Metabolic – recurrent hypoglycemia – send Ammonia in addition to BM, Lac, Ketones Think NAI as differential – strip for examination Surgical – failed to pass meconium 24-48 hrs Hirschprung disease, NEC, Pyloric stenosis Fluid Management Pitfall – Vaccine induced fever *Men B ~ 6 hrs

31. ANY QUESTION?

32. Summary Age-appropriate approach & management A to E assessment – ongoing & recurrent Talk to PED Nurses +/- Paeds SpR – concerns or no concerns Senior involvement +/- review Resources – AskEARL , PiP , NICE guidance, Senior think-tank, Paeds Team CPD learning – Spottingthesickchild.org.uk ; RCEMLearning induction module

33. THANK YOU