- Basics on Ventilation
- Presentation on Allergies including CMPA
- Other Haematological conditions
- Causes of fever in children
- Status Asthmaticus
- Upper airway Obstruction
- Sickle cell crisis
- Status Epilepticus
- Preterm Newborn
Basics of Ventilation
Presentation on 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)
- Viral URTI (most common cause), though they may not be overtly coughing a lot including pharyngitis, laryngitis, tonsillitis.
- Lower Respiratory tract infection, including bacterial and viral causes.
- UTI (Always dip the urine if you don’t have a clear focus / Pyelonephritis
- Acute Gastroenteritis / Gastritis / Diarrhoea (infective)
- Ear infection
- Sepsis (Neonates)
- Appendicitis / Cholangitis / Hepatitis / Pancereatitis (Usually older children)
- TB – Pulmonary / Miliary / abdominal
- Meningitis / Encephalitis
- Septic arthritis / Osteomyelitis
- Periorbital celluitis
- Vasculitis including Kawasaki’s disease
- Endocarditis (Rare in my experience)
- Tooth abcess
- Rarely malignancies including lymphomas
- Overseas visit – Malaria, Typhoid etc.
Talk to ID team, Rheumatology, Oncology etc.
- Rule out Foreign body / Anaphylaxis / anything else
- Check saturation and other Obs
- Provide O2 if needed
- Consider burst therapy with Salbutamol / Ipratropium
- Steroids – Prednisolone / Hydrocortisone
- Will IV access be needed – If not improving, do it – Do you need gas (K)
- Things not improving – IV MgSO4 / IV Salbutamol bolus
- Inform Consultant
- ? Chest X-ray
- IV Salbutamol / IV Aminophylline bolus
- IV fluids (mainly for K)
- IV Aminophylline infusion
- CATS / STRS / Local Paediatric Transfer team
- Anaesthetic review
- Consider Optiflow
Upper airway Obstruction
- Rule out Foreign body. Could it be Epiglottitis / Bacterial Tracheitis / Diptheria (immunised?)
- Try not to upset the child, keep with parents
- Do you need to involve Anaesthetics / ENT
- Observations – Saturations etc. – Humidified O2 if needed
- Is it Croup? (Laryngotracheobronchitis)
- Wesley score
- Consider giving oral Dexamethasone
- Can’t take orally / vomited – Budesonide nebulisation
- Severe – Adrenaline neb (to buy time)
- Inform Consultant
- Consider Chest X-ray
- Inform CATS
- IV access?
- Antibiotics (Bacterial Tracheitis / Epiglottitis)
- Anaesthetics / ENT
Sickle cell crisis
- Known – Previous admissions?
- Chest crisis – ? infection (fever)
- Obs – O2 saturations?
- Give O2
- Good analgesia – Paracetamol, Ibuprofen, Codeine
- Don’t hesitate to use Morphine
- Do you need IV access/ Check Hb, CRP
- ? Chest X-ray
- Hydration status
- Consider IV fluids (not sure if there is evidence for hyperhydration though)
- Discuss with consultant / haematologist
- Hb very low – ? Transfusion
- Severe sickling crisis – look for indications for Exchange transfusion
- Do you need to transfer to tertiary centre ? Transport team
Status Epilepticus (Seizures for > 45 min, or not waking up between clusters of seizures)
- O2 / Check Blood Glucose
- Look at APLS protocol
- Have they been given Diazepam by ambulance / Midazolam by parents?
- Benzodiazepines – Buccal Midazolam – Wait for 10 min
- IV access , inform Consultant
- If already have had 2 BZD, move to next step
- Consider Paraldehyde (Though not in APLS protocol, works very well in some cases)
- Phenytoin / Phenobarbital (if already on Phenytoin)
- Call anaesthetists
- Airway / Breathing (Difficult to assess if seizing)
- ? Infection / aspiration. Consider ABx
- Inform CATS
- Rapid Sequence Induction if still fitting
- Will you be able to extubate (worth considering if child stabilizes) – stop sedation / paralysis
- If unable to extubate – Sedation and paralysis may be required – Morphine / Midazolam
- Confirm diagnosis (winter season / infants / blocked nose / crepts / wheeze)
- Rule out cardiac condition (HR, saturations, pulses, murmur, liver edge etc.)
- Obs – Give O2 if needed (keep sats >94%)
- ABC D (Glucose)
- Assess hydration / feeding / wet nappies / CRT
- Calculate intake (should at least be taking ½ to 2/3 normal maintenance)
- If really congested – Try Hypertonic saline neb (2.7-3% saline) – Confusing evidence
- Suction if appropriate
- Consider Chest X-ray (Not really indicated- but be realistic)
- 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