Paeds on-call

Basics of Ventilation

Ventilation startegies

Presentation on Allergies including CMPA

Allergies including CMPA


Neutropenia is defined as a neutrophil count of less than 2 x 109 /l.Risk of infective complications is closely related to the depth of the neutropenia: a major increase in infections is seen with counts of <0.5 x 109 /l while some increased risk of infection is seen with counts of 0.5-1 x 109 /l. Causes of neutropenia include viral infection, sepsis, drugs, autoimmune disorders and bone marrow failure due to aplasia, malignant infiltration or severe B12 / folate deficiency. The following should be referred urgently for outpatient assessment: • Neutrophil count < 1 x 109 /l (ND ethnic origin is important see below) • Neutropenia in association with: other cytopenia lymphadenopathy splenomegaly Patients with active sepsis in association with unexplained neutropenia < 1 x 109 should be discussed with the duty haematologist to arrange appropriate direct assessment Appropriate investigation in primary care for patients not meeting criteria for urgent referral: • Blood film examination • Autoimmune screen • Consider discontinuation of potentially precipitating medications • Repeat FBC in 4-6 weeks – viral neutropenias are frequently transient Please note: Normal neutrophil count can be <1.0 x 10^9 /L in individuals of Afro-Caribbean or Middle Eastern origin. This could be benign ethnic neutropenia (B.E.N.) and this has a high incidence in our local population. Suggested asessment in primary care of a patient who is asymptomatic and has a neutropaenia without or without an accompanying mild thrombocytopaenia but normal haemoglobin. The blood test should be repeated 6-8 weeks later with a blood film and a review of medications that may contribute to lowering of neutrophil count e.g. anti-psychotic drugs Olanzapine or a high dose of Omeprazole. If the FBC is similar and there are no other precipitating causes then a diagnosis of B.E.N may be made. Referral for specialist opinion should be considered for: • Neutropenia associated with increased susceptibility to infection • Other unexplained, progressive neutropenia.

Other Haematological conditions

Causes of fever in children (You can get a long list from textbooks, but this is real)
  1. Viral URTI  (most common cause), though they may not be overtly coughing a lot including pharyngitis, laryngitis, tonsillitis.
  2. Lower Respiratory tract infection, including bacterial and viral causes.
  3. UTI (Always dip the urine if you don’t have a clear focus / Pyelonephritis
  4. Acute Gastroenteritis / Gastritis / Diarrhoea (infective)
  5. Ear infection
  6. Sepsis (Neonates)
  7. Appendicitis / Cholangitis / Hepatitis / Pancereatitis (Usually older children)
  8. TB – Pulmonary / Miliary / abdominal
  9. Meningitis / Encephalitis
  10. Septic arthritis / Osteomyelitis
  11. Periorbital celluitis
  12. Vasculitis including  Kawasaki’s disease
  13. Endocarditis (Rare in my experience)
  14. JIA
  15. Tooth abcess
  16. Rarely malignancies including lymphomas
  17. Overseas visit – Malaria, Typhoid etc.

Talk to ID team, Rheumatology, Oncology etc.

Status Asthmaticus
  1. Rule out Foreign body / Anaphylaxis / anything else
  2. Check saturation and other Obs
  3. Provide O2 if needed
  4. Consider burst therapy with Salbutamol / Ipratropium
  5. Steroids – Prednisolone / Hydrocortisone
  6. Will IV access be needed – If not improving, do it – Do you need gas (K)
  7. Things not improving – IV MgSO4 / IV Salbutamol bolus
  8. Inform Consultant
  9. ? Chest X-ray
  10. IV Salbutamol / IV Aminophylline bolus
  11. IV fluids (mainly for K)
  12. IV Aminophylline infusion
  13. CATS / STRS / Local Paediatric Transfer team
  14. Anaesthetic review
  15. Consider Optiflow
Upper airway Obstruction
  1. Rule out Foreign body. Could it be Epiglottitis / Bacterial Tracheitis / Diptheria (immunised?)
  2. Try not to upset the child, keep with parents
  3. Do you need to involve Anaesthetics / ENT
  4. Observations – Saturations etc. – Humidified O2 if needed
  5. Is it Croup? (Laryngotracheobronchitis)
  6. Wesley score
  7. Consider giving oral Dexamethasone
  8. Can’t take orally / vomited – Budesonide nebulisation
  9. Severe – Adrenaline neb (to buy time)
  10. Inform Consultant
  11. Consider Chest X-ray
  12. Inform CATS
  13. IV access?
  14. Antibiotics (Bacterial Tracheitis / Epiglottitis)
  15. Anaesthetics / ENT
Sickle cell crisis
  1. Known – Previous admissions?
  2. Chest crisis – ? infection (fever)
  3. Obs – O2 saturations?
  4. Give O2
  5. Good analgesia – Paracetamol, Ibuprofen, Codeine
  6. Don’t hesitate to use Morphine
  7. Do you need IV access/ Check Hb, CRP
  8. ? Chest X-ray
  9. Antibiotics
  10. Hydration status
  11. Consider IV fluids (not sure if there is evidence for hyperhydration though)
  12. Discuss with consultant / haematologist
  13. Hb very low – ? Transfusion
  14. Severe sickling crisis – look for indications for Exchange transfusion
  15. Do you need to transfer to tertiary centre ? Transport team
Status Epilepticus (Seizures for > 45 min, or not waking up between clusters of seizures)
  1. O2 / Check Blood Glucose
  2. Look at APLS protocol
  3. Have they been given Diazepam by ambulance / Midazolam by parents?
  4. Benzodiazepines – Buccal Midazolam – Wait for 10 min
  5. IV access , inform Consultant
  6. If already have had 2 BZD, move to next step
  7. Consider Paraldehyde (Though not in APLS protocol, works very well in some cases)
  8. Phenytoin / Phenobarbital (if already on Phenytoin)
  9. Call anaesthetists
  10. Airway / Breathing (Difficult to assess if seizing)
  11. ? Infection / aspiration. Consider ABx
  12. Inform CATS
  13. Rapid Sequence Induction if still fitting
  14. Will you be able to extubate (worth considering if child stabilizes) – stop sedation / paralysis
  15. If unable to extubate – Sedation and paralysis may be required – Morphine / Midazolam
  1. Confirm diagnosis (winter season / infants / blocked nose / crepts / wheeze)
  2. Rule out cardiac condition (HR, saturations, pulses, murmur, liver edge etc.)
  3. Obs – Give O2 if needed (keep sats >94%)
  4. ABC D (Glucose)
  5. Assess hydration / feeding / wet nappies / CRT
  6. Calculate intake (should at least be taking ½ to 2/3 normal maintenance)
  7. If really congested – Try Hypertonic saline neb (2.7-3% saline) – Confusing evidence
  8. Suction if appropriate
  9. Consider Chest X-ray (Not really indicated- but be realistic)
  10. Criterion for admission – WOB, Sats, Feeding, Parents!!
Preterm Newborn (Relatively stable one) Remember Golden hour!

Call for help (if you think).

  • After Resuscitation and stabilization, move to NNU / SCBU
  • Measure the temperature, keep warm
  • Check Blood Glucose, attach monitoring
  • Assess need for O2 / ventilatory support like Optiflow
  • Do you need an IV line (For fluids / Abx etc)?
  • If putting IV cannula, do you need to take blood for FBC, CRP, c/s, gas?
  • Do you need a Chest x-ray? Put an NG tube if you’re getting one
  • Update parents, try to leave the baby undisturbed for some time, if safe.
  • Getting better / worse – Call for help, if already not there.
  • Look at the child – breathing getting better / worse / not adequate