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![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](https://image.slidesharecdn.com/paediatricemergencies-211203110717/85/Paediatric-Emergencies-6-320.jpg)
Uploaded byMisbahuddin Mohammad
Paediatric Emergencies
This document provides guidance on approaching and managing common pediatric emergencies. It emphasizes taking an age-appropriate approach, thorough history and examination, involving pediatric nurses and specialists as needed, following guidelines like NICE, and considering rare or serious diagnoses. Common presentations like fever, wheezing, injuries and seizures are discussed. The importance of senior review, ongoing assessment, and team-based care for sick children is stressed.
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- 2. APPROACHING CHILDREN WHEN VULNERABLE •Strangers • Strange environment • Rapport building • Play • Distraction • Check with PED Nurses • Listen to parent/carer concerns
- 3. HISTORY TAKING • Sourceof 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 examwithout 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 • Feverincluding Croup • Wheeze, DIB • Injuries • ***NEEDLE in a HAYSTACK – SEPSIS & SAFEGUARDING CONCERN
- 6. FEVER • URTI (includingTonsillitis) &/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 • THINKSEPSIS – 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 High Risk Pale /mottled / ashen / blue No response to social cues Unable to rouse or unable to stay awake Weak / high pitched / continuous cry Appears ill Grunting RR > 60 Moderate to severe recession Skin turgor 1 sec or more Non-blanching rash Bulging fontanelle or neck stiffness Focal neurology or seizures Status epilepticus Atypical febrile convulsion Temp 38 or more if 0 - 3 months Bile-stained vomiting or swollen y No below PETECHIAE IN CHILDREN – THE PIC STUDY LANCET APRIL 2020
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- 13. 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 Clinical features May include one or more of the following: Persistent Fever > 39 C Lethargy and Myalgia Abdominal Symptoms: Pain, Diarrhoea and Vomiting Rash/Conjunctivitis Hypotension (Wide pulse pressure), tachycardia +/- Shock Initial management Examination: Exclude potential septic foci and careful cardiac assessme (liver, JVP, cardiac / thoracic ratio on CXR) Resuscitation: If signs of shock – fluid resuscitation (10ml/kg aliquots) wit shock. This syndrome has some clinical similarities to Kawas illness. In the majority of patients, coronavirus has not been d SARS-CoV-2 infection is present in some. The likeliest mechan Significant similarity in presen Septic shock - may require higher volume fluid resuscitat Peritonitis -negative laparotomy reported in some cases: ediatric Critical Care ediatric Multisystem Inflammatory Syndrome temporally associated with SARS-CoV-2 Clinical features include one or more of the following: ersistent Fever > 39 C thargy and Myalgia bdominal Symptoms: Pain, Diarrhoea and Vomiting ash/Conjunctivitis ypotension (Wide pulse pressure), tachycardia +/- Shock Covid-19 pandemic has been temporally associated with the emergence of a paediatric presentation of severe inflammatio k. This syndrome has some clinical similarities to Kawasaki shock and toxic shock. Patients have presented with mild to s ss. In the majority of patients, coronavirus has not been detected by PCR on throat/nasal swabs, however serological eviden S-CoV-2 infection is present in some. The likeliest mechanism is a delayed antibody-mediated dysregulated host immune resp Laboratory features Hyponatraemia Raised CRP Raised Ferritin (>500) Raised Troponin and B-NP Raised Fibrinogen Lymphopenia / neutrophilia Raised D-Dimer Platelets initially low or normal Renal dysfunction Significant similarity in presentation with other paediatric conditions ic shock - may require higher volume fluid resuscitation and source control: senior clinical review
- 14. FEBRILE SEIZURE • Aged6 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
- 15. BRONCHIOLITIS – RSV •Wheeze vs Stridor vs Grunting • Inhaler vs Nebs • Salbutamol vs Atrovent • Symptomatic & feeding support • Nasal saline +/- suction • +/- Oxygen – • Consider HFNO – • Escalation
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- 18. DISCHARGE CRITERIA FORBRONCHIOLITIS • Oxygen Saturations maintained in air O2 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.
- 19. 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)
- 20. BTS CLASSIFICATION OFWHEEZE/ASTHMA
- 21. BTS MANAGEMENT –FIRST LINE OF TREATMENT
- 22. BTS MANAGEMENT –SECOND LINE OF TREATMENT
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- 24. DKA • DKA Calculator •BSPED DKA Flowchart
- 25. AFEBRILE SEIZURE/EPILESPY • A toE Assessment • Contemporaneous management • DON’T FORGET ‘G’ • First fit • Known epileptic • Difficult fitter – advanced care plan
- 26. 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
- 27. INJURIES – HEADINJURIES • NICE Head Injury guidance to follow • MOI • Scary sight for parents – LOC, Drowsy, Irregular Breathing, Floppy, Palor Usually come around in few minutes – observation
- 28. INJURIES – LIMBINJURIES • 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
- 29. NON-ACCIDENTAL INJURIES • Story– MOI, TOI (any delay – reason) • Witness • Corroborate – story vs injury sustained • Low threshold • Professional curiosity • Pattern – bruising - Body Mapping
- 30. 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
- 31. 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
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- 33. 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
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