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what are the 2 main causes of cardiac arrest?
what are the 2 main categories of respiratory failure with 3 eg of each?
: foreign body, asthma, croup/acute epiglottitis
: convulsions, poisoning/drugs, raised ICP
what are the 2 main categories of circulatory failure with 3 eg of each?
: blood loss, burns, D&V
: sepsis, anaphylaxis, cardiac failure (peripheral/pulm oedema)
what is the main difference in cardio-resp arrest between children and adults
: it is usually at the end of physiological deterioration. they arrest because they are already so ill.
so even if defib - very high death rate
how can you tell if A&B are at a cricital state?
increased work of breathing - ie respiratory distress
absent or decreased respiratory effort - due to exhaustion or respiratory depression
what are the 3 main key signs to look for in A&B
effect ie adequacy of oxygenation
what 5 things do you look for - effort of breathing?
inspiratory or expiratory noises (stridor or wheeze)
use of accessory muscles/paradoxical breathing
how do you assess the efficacy of air entry?
how do you assess the adequacy of oxygenation?
what are the 4 signs of potential circulatory failure (shock)?
pulse volume reduction - weak peripheral, if weak central then
increased cap refill time >2s
BP low - preterminal sign
what are the effects of circulatory failure on the body?
metabolic acidosis with increased respiratory rate (to compensate)
: pale, mottled, cold
: agitation then drowsy as reduced cerebral perfusion
: oliguria as reduced renal perfusion
what are the 3 signs of potential CNS failure?
level of consciousness
: dilatation, unreactivity, inequality
what are the effects of CNS failure?
abnormal respiratory patterns
systemic hypertension with sinus bradycardia - Cushing's response (indicates herniation of cerebellar tonsils through foramen magnum)
what is the most common cardiac arrest rhythm in children?
what is the treatment for cardiorespiratory arrest?
shout for help
approach with care
free from danger
: ask loudly as you all right? do not shake in case c-spine injury
shout for help if unresponsive (if responsive then leave child in same position and reassess regularly, get help if needed)
turn child to his back
open airway using head tilt chin lift
look listen feel for breathing only for 10s
if breathing normally - then recovery position - get help
if breathing is NOT normal then
- remove obvious airway obstruction
- 5 initial rescue breaths
- note any gag or cough response to your action.
: signs of life, carotid pulse in neck if >1yo or brachial pulse if <1yo
if detect signs of circulation then continue rescue breaths
if no signs of life start chest compression rate of 100-120/min
15 compression then 2 effective breaths
due for 1 minute then call for help
after BLS, what 3 things may you need to do for the child in cardioresp arrest?
: circulatory access - venous or intraosseous, ECG monitor
what are the 2 ways of giving chest compressions to an infant?
2 finger technique if ALONE
hand encircling and using thumbs on lower half of sternum
what is method of chest compression for a small child?
one handed - heel of the hand over lower half of sternum
lift fingers so pressure not applied to ribs
once you have a heart rhythm, which are the shockable and which are non shockable?
: VF, pulseless VT - then give 1 shock 4J/kg then immediately CPR 2 minutes
: PEA, systole - immediately resume CPR 2 minutes
what are the reversible causes of cardioresp arrest?
: hypoxia, hypovolaemia, hypothermia, hyper/hypoK+
: thrombosis, tension PT, toxins, tamponade
what are the 4 main causes of upper airway obstruction?
foreign body inhalation
what is the cardinal sign of upper airway obstruction?
: noise associated with breathing due to obstruction of extrathroracic airway
worse on inspiration
what are features of severe upper airways obstruction?
poor air entry
chest wall recession
decreased conscious level
what are 3 main features of acute croup?
dry, barking cough
low grade fever <38.5
what age does croup usually affect?
3month - 5yr
which croup differential is difficult to distinguish from croup?
it will become apparent when there is deteriorating course without antibiotics
what is the management of croup?
gentle confident handling - avoid unnecessary upset for child
monitor O2 sats and heart rate
give O2 - wafting
seek help if intubation and ventilation required
nebulised budesonide (steroid) or oral dexamethasone
nebulised adrenaline (5ml of 1:1000)
: transient relief to buy time for steroids to work or intubation
why is epiglottitis becoming uncommon?
what is management of acute epiglottitis?
call for help - senior pads, anaesthetist, ENT surgeon
KEEP CALM, DO NOT LIE DOWN, DO NOT EXAMINE THROAT - any distress can further compromise airway so defer until full support available
expert will intubate and ventilate
then swab epiglottis and take blood cultures
iv antibiotics - iv ceftriaxone 80mg/kg/day
what are the causes of lower airways obstruction?
what are the RF for acute asthma attack?
: long duration of symptoms, night wakening
previous attack needing IV therapy or PIC
poor response to Rx in current episode
what are the features of acute SEVERE asthma?
too breathless to talk or feed
O2 sats < 92%
recession and accessory muscle use
what is the management of acute SEVERE asthma?
high flow oxygen
: via large volume spacer 10 puffs of salbutamol 100mcg each.
or nebulised SABA 2.5 (up to 12yo) -5mg (12-18yo).
repeat SABA 10-20mins
predisolone 1-2mg/kg, max 40mg. or iv hydrocortisone 4mg/kg
if poor response give inhaled ipratropium bromide
what are features of life threatening asthma?
poor respiratory effort, exhaustion
O2 sats < 92%
reduced level consciousness
peak flow <33%
what is Rx of life threatening asthma?
high flow O2
(iv salbutamol, Mg, aminophylline)
burst therapy - back to back bronchodilators. 3 in an hour. reassess after each burst
what is the commonest serious respiratory infection in infancy?
what is bronchiolitis characterised by?
what causes bronchiolitis?
direct inflammation of bronchiole walls and mucus plugging
: RSV, metapneumovirus, influenza, parainfluenza
how does bronchiolitis present?
acute DIB - SOB, inc effort
recurrent apnoea in neonates
signs of dehydration
what Qs need to ask mother in bronchiolitis?
ability to feed
underlying cardio/resp disease
what is the management of bronchiolitis?
monitor O2 sats, RR, HR
airway/nasal passage clearance
: may reduce respiratory distress (Yankauer suction catheter at nares)
give humidified O2 by headbox or nasal cannulae to maintain O2 sats >94%
: oral feed (mild), NG feed (mod), iv fluids (severe)
can give nebulised hypertonic saline (3%) to draw water into lungs away from airways
adrenaline can reduce the oedema and buy time
CPAP can keep airways open and make easier to breathe
which 3 drugs have no role in bronchiolitis?
NO role for bronchodilators, steroids or antibiotics!
what is Rx when there is exhaustion or apnoea?
as will become hypoxic and hypercapnic
what is the definition of shock?
acute failure of circulatory function
leading to poor TISSUE PERFUSION
what are the 2 common causes of shock in chidlren?
distributive - sepsis/anaphylaxis
what are the early physical signs of shock?
: due to vasoconstriction
tachycardia with reduced pulse volume
poor skin perfusion
: cold, long cap refill
signs of bleeding
what are the late signs of shock? think of END ORGAN FAILURES!
rapid deep breathing
: response to metabolic acidosis
agitation, confusion due to brain hypoperfusion
: <2ml/kg/h in infants and <1ml/kg/h in children
if there is warm shock what does that indicate?
toxin mediated - gut organisms
what is the Rx of circulatory shock?
iv access x2
if no improvement repeat 20ml/kg normal saline
reassess if still no improvement
how do you manage anaphylactic shock?
ABC, remove allergen
lie flat, raise legs
im adrenaline 1:1000 10ug/kg
20ml/kg fluid if shocked
repeat adrenaline, fluids every 5 mins if no improvement
: iv hydrocortisone
: pulse, ECG, BP
what are the main causes of septic shock? organisms
: staph, strep
what shape and gram is n.meningitides?
what are features of early septic shock (ie compensated)
increased cardiac output
decreased systemic resistance
what are features of late ie decompensated septic shock?
what is the cardinal sign of meningococcal septicaemia?
petechial or purpuric rash
in early stage may be blanching
if meningococcal sepsis is suspected what must be done asap?
how do you manage septic shock?
: give oxygen
: HR, BP, cap refuel - iv access, blood tests, fluids 20ml/kg
: iv ceftriaxone
: blood glucose, blood gas - acidosis, DIC
level of consciousness assess
: check fontanelles, LP
may need ITU - continuous monitoring - central venous pressure, UO, pulse O2
in DKA, why do you get production of ketones?
without insulin, G cant be taken into cells and used
so fat is used as energy source - leading to ketone production and metabolic acidosis
what are symptoms of DKA in a new diabetic?
polyuria due to osmotic diuresis
polydipsia to compensate
what is trigger for known diabetic in DKA and symptoms
intercurrent illness eg infection
poor control of glucose levels
may have poor compliance with insulin
what are the 4 essential Ix in DKA?
: glucose, ketones
what are the typical abnormalities in DKA
blood glucose > 15mmol/l
: increased urea, Na low, K can be low/normal/high depends on renal function and degree of acidosis
: metabolic acidosis low pH, HCO3 low, PaCO2 low as respiratory compensation
what are the 3 main categories of signs in DKA?
: dry MM, reduced skin turgor, tachycardia, hypotension
: ketones breath, kussmaul
: headache, decreased conscious, seizure, high ICP signs
in DKA what is total body K+ like?
how do you prevent cerebral oedema?
slow metabolic correction and rehydration
how do you treat DKA?
: treat shock, maintenance fluids rehydrate over 48hours (in case cerebral oedema)
0.9% saline initially
: iv 0.1U/kg/h
avoid drops of G >5mmol/l/h
when glucose < 14 add dextrose
add K+ after giving insulin - need ECG monitor
treat cause - infection
what things need to be monitored in DKA?
fluid balance - input, output, weight
vital signs, near - ceberal oedema
what are the 2 main complications of DKA?
: prevent by avoiding rapid falls in glucose or Na
: K+ levels
what is status epilepticus?
continuous/recurrent seizures >30mints
where pt doesn't regain normal baseline mental state
what are causes of status epileptics?
: hypoglycaemia, poison
what is Rx of status epilepticus?
ABC - may need nasopharyngeal airway
iv access - check glucose, calcium, Mg
iv lorazepam --> still after 10 mins then more lorazepam
if no iv access then PR diazepam or buccal midazolam --> still seizing then iv lorazepam or if no iv access then PR paraldehyde mixed with olive oil
still seizing then iv phenytoin (infusion under ECG and BP monitoring) or phenobarbitone if already on phenytoin
intraosseous if no iv
then paralyse and intubate and ventilate
treat on ICU - thiopentone or BZD infusion
what are causes of high ICP?
what are symptoms of high ICP?
: bradycardia and hypertension
what is Rx of ICP?
30 degrees head up
aim is to reduce activity of brain to reduce blood supply and reduce oedema
intubate, sedate, paralyse
need to maintain normoCO2
iv mannitol or 3% saline to reduce oedema