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TPCH, Children’s ED: Resident Education: Dr Kate Edgworth: Last Edit 12/6/17

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TPCH Children’s

Emergency Department

Resident Education

Workbook

Created by Dr Kate Edgworth, Senior Registrar, TPCH, Children’s ED For use within TPCH Children’s ED Only


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Contents

Topic Page Introduction to Resident Teaching 3 How to make a referral 4 Recognizing the Sick Child 6 Advanced Paediatric Life Support Algorithm 8 Gastroenteritis and Fluid Prescriptions 9 Asthma and Viral Induced Wheeze 11 Croup and Airway Obstruction 13 Bronchiolitis and LRTI 15 Fever 17 UTI 19 Cellulitis 21 Vomiting 22 Appendicitis and Abdominal Pain 24 Head Injury 26 Upper Limb Fractures 28 Lower Limb Fractures 30 Febrile Neonate 31 Neonatal Jaundice 33 The Normal Neonate 35 Seizures 36 DKA 38 Hypoglycaemia 40 Cardiac Presentations 41 Eating Disorders 43 Rashes 45 Record of sessions attended 49 Feedback of sessions attended 50


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Introduction to Resident Teaching

Teaching Timetable

Monday Tuesday Wednesday Thursday Friday AM 0900 -‐ 1000

LCCH radiology teleconference

1100 -‐ 1300 M&M (1st Thursday of the month)

0900 -‐ 1000 LCCH radiology teleconference

PM 1400 -‐ 1500 Resident teaching

1430 -‐ 1500 SIM

1500-‐1600 Radiology teaching

1400 -‐ 1500 Resident teaching

GREEN All available staff to attend BLUE All residents to attend PURPLE All registrars to attend (residents may attend if available) ORANGE All rostered on for teaching to attend Resident Teaching

• Dedicated Children’s ED resident teaching occurs on Monday and Friday at 14:00 in the Children’s ED Handover Room

• All residents who are rostered that day are expected to attend • Please aim to tidy up and package your patients by the start of teaching • You are welcome to eat your lunch during the teaching session • Each session will go through one of the topics in the resident education

workbook • It would be useful to review the questions prior to the teaching session • We recommend you go through the topics not covered in your teaching

sessions in your spare time as these will be reviewed in your Resident Feedback sessions

• All the questions are based around clinical guidelines which can be found on tpched.org and ED dragon

• Please keep a log of all the teaching sessions attended on page of this workbook

• Please fill in feedback for all the sessions you have attended, these can be handed in at your regular resident review meetings


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How to make a referral to an Inpatient Team

An SBAR approach is a good system to ensure you give all the details in a systemic way. Think about what the person you are speaking to will want to know, have the notes, drug chart and observation sheets available so that you can answer any appropriate questions Introduction

• Explain your name, role and division • Explain what you want from them (e.g. I’m ringing for your advice or I’m

ringing because I have a patient who needs a paediatric review or I’m ringing as I have a patient who I think needs admission)

‘Hi, it’s Nicholas from Children’s ED. I am phoning because I have a child who needs a paediatric review for possible admission’ Situation (core details)

• Patient Details (Name, age) • Patient Location • Presenting Problem or Major Complaint (Reason for referral)

‘The patient is Jack Smith, a 3 year old boy with a viral induced wheeze in bed 8, who I am referring for your opinion because he is still only stretching an hour after initial burst therapy and is now hypoxic requiring 2 L of O2 to keep his oxygen sats at 92%’ Background (admission and history)

• Past medical history • Previous admissions • Any other relevant history and important negatives

‘He has had a runny nose for 2 days and increased work of breathing since this morning. Jack has had two previous presentations with the same problem, once requiring high flow oxygen. He has never needed ICU. He doesn’t really suffer with any interval symptoms and only seems to get wheezy with a viral illness. He is otherwise atopic with hay fever and eczema but has no other significant medical history. Mum is especially concerned as her sister died of asthma in childhood.’


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Assessment • Vital Signs • Examination findings • Investigations received/ pending • Management so far

‘On arrival he had a widespread bilateral wheeze and a tight sounding chest. There were no focal signs on the chest. He responded to an initial burst with some improvement in air entry but we have been unable to stretch him beyond 45 minutes. He has had prednisolone 2mg/kg and currently has EMLA on in case he needs an IV line and therapy. His current HR is 156, Sats 92% on 2L NP, RR 46 with a CEWT score of 5. He has been afebrile throughout’ Recommendation

• Diagnosis/ Differentials • Management Plan

‘I think he has a viral induced reactive airways disorder with some response to salbutamol but think he may need escalation to IV therapy and an extended stay due to his slow salbutamol stretch.’ Practice creating SBAR’s for the following situations or about patients you have seen over the first week. You can create your own history, PMH, observations and examination to suit each situation

• A 5 year old boy with a fever, likely UTI and previous diagnosis of ureteric reflux

• A 4 day old baby with Jaundice and 11% weight loss since birth • A 2 year old girl with a complex febrile seizure • A 7 year old boy with a fever and petechial rash • A 3 month old girl with bronchiolitis and poor oral intake


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Recognizing the Sick Child

1. Name one physiological difference in children compared with adults for each of the following categories: Airway, Breathing and Circulation

2. Complete the following table with the normal observations for children of

different ages. Age RR HR Minimum SBP Infant Toddler Pre-‐School School Age Adolescent Airway 3. How would you assess a child’s airway? 4. If there were significant stridor on presentation would you make any

interventions? Breathing 5. What signs would you look for in a child that suggests increased work of

breathing?


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Circulation 6. What signs would you look for on examination to suggest adequate tissue

perfusion and effective circulating volume? 7. Describe how you would insert a peripheral IVC? What adaptions will you make

to your normal technique when performing this procedure on a young child? 8. If you are unable to insert an IV cannula in a critically unwell child, what would

be your next choice in obtaining definitive access and how would you perform this?

Disability 9. How would you assess an infant’s GCS? How does this differ to an adult? Exposure 10. What else would you look for in your initial primary survey that is not covered

within ABCD?


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Paediatric Advanced Life Support

Adrenaline 10 mcg/kg(immediately then

every 2nd loop)

Non-shockable PEA/asystole

CPRfor 2 minutes

Adrenaline 10 mcg/kgafter 2nd shock

(then every 2nd loop)

Amiodarone 5 mg/kgafter 3rd shock

Shock(4 J/kg)

Shockable VF / pulseless VT

CPRfor 2 minutes

Assessrhythm

Return of spontaneouscirculation?

Attach defi brillator/monitor

Start CPR

Post-resuscitation care

During CPRAirway adjuncts (LMA/ETT)OxygenWaveform capnographyIV/IO accessPlan actions before interrupting compressions (e.g. charge manual defi brillator to 4 J/kg)

Consider and correctHypoxiaHypovolaemiaHyper/hypokalaemia/metabolic disordersHypothermia/hyperthemiaTension pneumothoraxTamponade ToxinsThrombosis (pulmonary/coronary)

Post-resuscitation careRe-evaluate ABCDE12 lead ECGTreat precipitating causesRe-evaluate oxygenation and ventilationTemperature control (cool)


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Gastroenteritis and Fluid Prescription

Case 1 An 18-‐month-‐old girl presents to ED after several vomits at home this morning. She seemed a bit off her food last night and woke up in the early hours of the morning when she started to vomit. Since then she hasn’t been able to keep anything down. She has had no fevers but has had one episode of diarrhoea prior to presentation. 1. How would you assess her fluid status? What would you look for on history,

examination and observations? 2. Other than looking a little coryzal and mildly dehydrated she examines well, how

are you going to treat her? 3. After 2 hours she has tolerated 300mls of gastrolyte and had no further vomits.

She appears well with normal observations and you think she may be able to go home. What advice should you give her parents on when to return? Where can you find patient handout information?

Case 2 An 18-‐month-‐old boy presents to ED with 24 hours of vomiting. He appears quite lethargic and is carrying a bucket. He has no fevers He is placed in a cubicle and started on a trial of oral fluids. After eating a gastrolyte ice block he vomits again and then falls asleep. 1. Would you consider prescribing an anti-‐emetic, which one would you choose and

what dose and route? 2. How are you going to deliver fluids to this child and at what rate?


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3. Describe how you would insert an NG into this child? Prescribing Fluids On the below fluid chart please prescribe the following: 4. Maintenance Fluids for a 12 year old boy who weighs 43kg

5. Fluid bolus for a septic neonate who weighs 3.6kg

6. Rapid Rehydration for a 6 year old girl with gastroenteritis who weighs 20kg

7. Slow rehydration over 24 hours for a 5 year old boy who weighs 16kg and is 5%

dehydrated 8. Maintenance fluid for a 8 day old baby who weighs 3.2kg

Question Total Amount Fluid Rate (mls/hr)

4

5

6

7

8


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Asthma and Viral Induced Wheeze

Case 1 2-‐year-‐old boys presents to ED with 2 days of coryza and cough and increased work of breathing this morning. He has had something similar before and was given a salbutamol inhaler which mum has been giving him every few hours at home. On presentation he has moderate increased WOB and when you listen to his chest he has global widespread wheeze. 1. What treatment would you start immediately after your initial assessment,

including the dose and mode of delivery? 2. What further questions would you ask on history to elicit the severity of his

illness? 3. Discuss whether you would use steroids in this child and if so what dose? 4. He seems to respond to the initial therapy, how would you manage this child

from this point? 5. After several hours he is well maintained on 3-‐4 hourly Ventolin. You are going to

discharge him home, what advice should you give to mum and what handout information should you include in your discharge pack?

6. Just as they are about to leave mum asks you if this means he has asthma, how

will you respond to this question?


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Case 2 A 7-‐year-‐old boy presents with worsening wheeze over the course of the morning. He has known asthma and is normally controlled on flixotide. He has been using hourly Ventolin at home over the last few hours with minimal improvement. On examination he has moderate to severe increased work of breathing and minimal air entry across his chest. His observations are Temp 37.4, HR 150, RR 54, Sats 87% on RA. 1. Comment on his observations 2. What features on examination suggest severe or life threatening asthma? 3. What immediate treatments will you initiate what dose and how will it be

delivered? 4. You decided to give back to back nebs and oral steroids but there is very little

improvement, what treatments would you use next? Can you describe a step wise approach to escalating treatment?

5. When inserting an IV line you take a venous gas, can you interpret the results

below and describe whether this will change your management? pH 7.32 pCO2 59 pO2 78 HCO3 24 Na+ 135 K+ 2.7


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Croup and Airway Obstruction

Case 1 A 3-‐year-‐old boy presents with sudden onset barking cough overnight. He seemed to have very noisy breathing at home but this has settled prior to presentation. He now examines well with no work of breathing but still has an intermittent barking cough. 1. How would you treat him? 2. How long does he need to stay in the emergency department? What advice will

you give to his parents on discharge? Case 2 A 2-‐year-‐old girl presents with her father with loud stridor and associated increased work of breathing. She was well before she went to bed but woke up suddenly with a barking cough and significant stridor. On examination, she is febrile, has moderate to severe tracheal tug and subcostal recessions with loud stridor. Her RR is 40 and Sats are 966% 1. What is your immediate management? 2. Following this management, she responds well. How long should she stay in the

department and what would your discharge criteria be? 3. If she had no improvement after the initial management, how would you

escalate your management? 4. If she was unimmunized how would this change your management?


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Case 3 A 4-‐year-‐old boy was playing with a coin when he accidentally inhaled it and started choking. After coughing for a few minutes, he had a colour change around his lips. On arrival to ED he was sitting up and drooling with soft stridor. 1. What are your concerns with the above presentation? What would be your

management priorities? 2. Imaging reveals a $1 coin in the upper airway, what are the next steps you would

take? Case 4 A 12-‐year-‐old female who is allergic to peanuts was at a friend’s house eating banana bread when suddenly she felt a tightness in her throat. She tried taking 10mg cetirizine but started vomiting. Her friend’s mum drove her to ED. On arrival, her obs are HR 120, RR 30, Sats 92% and BP 88/64. She has a hoarse voice and global wheeze and appears to be quite pale. 1. What is the first management step including the dose and route of

administration? 2. As well as the initial drug are there any other medications you would deliver? 3. How long would you keep her in the department for? 4. Where can you find discharge information on anaphylaxis and how will you

prescribe an epi pen?


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Bronchiolitis and LRTI Case 1 1. What is the classical history of bronchiolitis? What day of illness are the

symptoms at their worst? 2. What examination findings would you expect in bronchiolitis? 3. Which infants require admission? Are there any criteria you would use? 4. If a baby with bronchiolitis had oxygen sats in the high 80s how would you

manage this? 5. If a baby with bronchiolitis had only taken a 1/3 of its normal oral intake with

only 2 wet nappies in the last 24 hours, how would you support their feeding? 6. How might neonates with early bronchiolitis present? 7. When would you do an NPA (nasopharyngeal aspirate)? 8. What is the most common organism causing bronchiolitis?


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Case 2 A 6-‐year-‐old presents to ED with a cough for the last 2 weeks, it initially started with associated viral symptoms but the cough has persisted. It remains moist and productive and mum feels like she has been hot to touch 1. What are your initial differentials of a cough and what further questions would

you ask in the history to determine the most likely cause? 2. When would you investigate with a CXR? 3. Can you describe the following chest XRs and how you would manage each

scenario?

• Sats 99%, HR 130, Temp 38.6, RR 30

• Sats 88%, HR 110, Temp 38.1, RR 30

• Sats 91%, HR 140, Temp 39.2, RR 34


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Fever

Case 1 A well looking toddler presents to ED with intermittent fevers for last 24 hours. He is well in between fevers and mum has been using Panadol to control his temperature. His observations are all within normal limits including a HR of 126 and CRT < 2 secs and on examination he is coryzal with a slightly red pharynx. His temperature is 38.1. You decide he has a viral URTI and want to send him home but mum has some questions for you. 1. What is the best way to measure a temperature at home and how high does it

have to be to be classed as a fever? 2. How high is the fever allowed to go, should I be worried if it is over 40? 3. Should I keep giving him Panadol and Nurofen whilst he has a fever and how long

can I keep giving it for? 4. How long do the fevers normally last? 5. When should I come back, how do I know I he’s getting worse? Case 2 A 19-‐month-‐old boy presents with a high fever and looks quite miserable. Mum says he has been unwell for 2 days, beginning with a runny nose and a vomit yesterday. His Temp is 39.6, HR is 160, CRT 2 secs, RR 28 and Sats 100%. On exam, he is coryzal and has a red pharynx and tympanic membranes. 1. You think he has a viral URTI. Can he go home straight away and why? 2. You decide to keep him for some observation, what treatment would you

initiate? 3. Will you do any investigations at this point?


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4. How will you decide when he is ready to go home? Case 3 A 9-‐month-‐old, immunised girl presents with a high fever. Mum states today is day 3 of illness and every day she has had a fever over 38 degrees. She appears miserable when she is febrile and often vomits at the same time. At present, she looks quite well and is playing in the bed. Her Temp is 37.9, HR 160, CRT < 2 secs, RR 28. On examination, you cannot find a source for her fever. 1. What would you do at this point? Can she go home or does she need more

observation? Are you worried about anything? 2. Would you do any investigations at this point? Whilst observing her she begins to look more miserable, her temperature is 38.9, HR 172, CRT 3 seconds and looks a little mottled. 3. How would you change your management at this point, would you initiate any

treatment? 4. She appears quite lethargic, do you need to do an LP, how would you decide

this? Case 4 A 3-‐year-‐old child presents with a high fever, whilst examining her she is well but you notice a few petechial spots on her face and chest. 1. How would you manage this case? Would you do any investigations? Give

antibiotics? And what is her likely disposition?


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UTI

1. Can you list some risk factors for UTI? 2. How does a child under 6 months with a UTI present to ED, what type of

symptoms might they have? Case 1 A 5-‐year-‐old girl presents to ED with pain when she passes urine, her symptoms started this morning and mum noticed she also felt hot. She has a temp of 38.2 but otherwise normal observations and examination 1. How will you collect her urine and how will you advise her and her mum to do

this? 2. Will you dipstick her urine or just send it to the lab for testing? 3. What will you look for on the urine results to suggest she has a UTI? 4. If she has a UTI on microscopy what will be your choice of antibiotics? Dose? And

route of administration? 5. Does she require any follow up or further investigations?


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Case 2 A 5-‐month-‐old baby presents with high fevers and vomiting for 48 hours. There are no other focal symptoms or signs on exam and you are worried about a urinary tract infection. 1. How will you collect the urine from this baby? 2. The observations reveal a HR 170, Temp 38.4, RR 44. He is still vomiting. The

urine is positive for infection, how will you treat this boy including dose, route of administration of any drugs and disposition?

Case 3 A 15-‐year-‐old girl presents with pain on urination and fevers and wonders whether she has a UTI. On arrival she is febrile and flushed with a HR of 110. 1. What further questions would you ask in this age group to determine the cause

and also the risks? 2. On examination she has tenderness in her R flank, will this change your

management? 3. After her mother leaves the room she states she has recently had unprotected

intercourse. Her LMP was 3 weeks before but she has noticed some PV discharge in the last couple of days. Would this change your management? Will you talk to her mother about this?


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Cellulitis

Case 1 A 7-‐year-‐old girl presents with redness around a wound on her leg. It started as insect bite whist on school camp but as she scratched it the surrounding redness has increased. She is otherwise well and afebrile. There is a small scratch on her leg with around 4 cm of surrounding redness that is warm to touch. There is some yellow crusting over the wound. You think it is infected. 1. How will you treat this including the dose, frequency and route of administration 2. Mum asks you if she should keep the wound covered, what will you suggest? 3. How can mum monitor whether this is getting worse? Case 2 A 12-‐year-‐old boy presents with an infected wound to his R arm. He is unsure when the wound first started but it is getting progressively worse. He has a fever of 38.3 degrees and some lymphadenopathy in the ipsilateral axilla. 1. Will you do any investigations in this child? 2. How will you manage him? 3. How would you decide whether he needed MRSA cover? Case 3 A 14-‐year-‐old boy presents with a fluctuant area on his right thigh. He has a history of boils and you think this is the same thing. The area is around 2x2cm with some overlying erythema. 1. How would you manage him?


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Vomiting

Case 1 A 4-‐week-‐old baby boy presents with vomiting over the last week. Mum states he is a breast-‐fed baby but seems to be vomiting all of his feeds. 1. What further questions would you like to ask in the history to help determine the

cause of his vomiting? 2. What are the classic features on pyloric stenosis on history? 3. What are the key things you will look for on clinical examination? 4. What investigations would be the most helpful and why? 5. Your investigations point to a diagnosis of pyloric stenosis, how will you manage

this condition? Case 2 A 6-‐month-‐old baby presents to the emergency. He has had a recent viral URTI but seemed to be recovering. Today he has had very sudden onset abdominal pain with two vomits. On presentation he is having episodes of screaming and drawing up his legs up followed by being very flat and pale. You suspect intussusception. 1. What other features on history would support your diagnosis? 2. The mother asks you what intussusception is, how will you explain this?


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3. What would be your investigation of choice? 4. How will you manage this patient? Case 3 A 4-‐day-‐old baby presents with bilious vomiting. You are worried about obstruction. 1. What other questions will you ask in your history to help determine the cause? 2. What would you be looking for on clinical examination? 3. What are your differential diagnoses for bilious vomiting in a neonate? 4. What is your immediate management in this baby? 5. The babies XR is shown below, can you describe what you see?

6. What is this baby’s disposition?


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Appendicitis and Abdominal Pain

Case 1 A 13-‐year-‐old girl who is bought to ED by her mother has a 2-‐day history of abdominal pain and vomiting. Initially the pain was quite crampy but now is there all the time. She has had 2 vomits but normal bowel motions. 1. Before you start your history and examination you notice she appears to be in

pain and reports 8/10 discomfort, what analgesia would you prescribe and what is the dose?

2. What other questions would you like to ask to complete your history? 3. What features would you look for on examination? Her observations are as follows: Temp 37.9, HR 90, RR 16, CRT < 2 secs, weight 64kg. On examination she appears to be tender in the RLQ 4. What differential diagnoses are you considering at this point? 5. What investigations might you consider and why? Her results so far are published below Urine: 20 leucs, no bacteria seen FBC: Hb 112, WCC 16.3, Plts 210 CRP: 16 USS: Normal ovarian pathology, appendix not visualized


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6. What are your management options at this point? What is her likely disposition? Case 2 A 9-‐year-‐old girl presents to ED with her very anxious mother with 6 months of abdominal pain. There is occasionally associated nausea but no vomiting or changes to her bowels. She has no urinary symptoms, minimal appetite but no weight loss. She has presented to the GP several times and has had a FBC, ELFTs, CRP and Urine MCS this week that are all normal. 1. Are there any other things you want to ask on the history specific to this case? 2. With no further positives in the history and a normal abdominal examination,

what is your current list of differential diagnoses? 3. Would you consider any other investigations today or further investigations and

follow up in the community? Case 3 A 5-‐year-‐old boy presents after not having opened his bowels for 6 days. His father reports small solid stools every 4-‐6 days. Abdominal exam reveals a palpable mass in the LLQ and you suspect he has constipation 1. How might you manage this child and how should he be followed up? What

information will you give to the parents about both diet modifications and pharmacological treatment


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Head Injury Case 1 A 3-‐year-‐old boy presents to ED with his mum at 5pm after running, tripping and hitting his head on the corner of the couch. He cried immediately but has a large bump on his forehead so has been bought in for assessment. 1. What further information would you look for in the history specific to this

presentation 2. What would you be looking for on examination? After your history and examination you decide that there are no significant risk factors and he examines well. It is now 7pm and he is playing in the waiting room after eating an ice block. 3. What is this child’s likely disposition? What factors would influence your

decision? 4. Once this child is discharged, what information are you going to give to mum and

what follow up should be arranged? Case 2 A 14-‐year-‐old boy was hit in the head during a tackle in a rugby game. He says he can’t remember what happened and vomited shortly after. The coach called an ambulance and on arrival to emergency he is a little drowsy and is triaged a cat 3 1. How do you assess this child’s GCS?


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2. How might you decide if this child needs imaging? Are there any specific rules or criteria available? Where might you find them and what do they state?

3. He has a CT that is reported as normal but is still vomiting; he is now 4 hours post

the initial injury. What might you do next? 4. The next day he is well and discharged home, what advice would you give to him

and his family about his return to sport? Case 3 A 3-‐month-‐old girl has fallen from the change table an hour before, cried straight away and seems to have been well since. She has had a breast-‐feed and examines well in the department. 1. What other important considerations are there to think about in this case? Case 4 A 3-‐year-‐old boy presents with 6 vomits this morning. Whilst taking the history mum states he fell from the play equipment at day care yesterday morning and sustained a bruise to the back of his head. 1. How might you manage this child? Do you think the head injury is significant and

how might you come to this conclusion?


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Upper Limb Fractures

Case 1 A 2-‐year-‐old boy presents with his father. As he was crossing the road he tripped and his dad pulled him up by his wrist. Following this is cried immediately and has not been using his R arm. On presentation to ED he appears well but is reluctant to move his R arm and cries when you palpate the elbow, examination is otherwise unremarkable. 1. What is his most likely diagnosis and how will you manage this? 2. If your initial management does not work, what would you consider next? Case 2 An 8-‐year-‐old girl falls on an outstretched hand whilst playing in the playground. She complains of pain in her wrist and is tender over her distal radius. There is minimal swelling and no deformity. Her XR is below 1. Describe the XR 2. How would you manage this case?


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Case 3 A 7-‐year-‐old girl falls off the trampoline landing on an outstretched hand. She complains of pain when moving her elbow and there is swelling around the same area. Her XR is below 1. What does the XR show? 2. How would you manage this case? Case 4 A 12-‐year-‐old boy falls off his bike and presents with significant deformity to his forearm. His XR is below 1. What analgesia would you prescribe on presentation? 2. Describe the XR 3. How would you manage this case?


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Lower Limb Fractures

Case 1 A 14-‐year-‐old girl rolls he ankle during a netball game and is now unable to weight bear. She complains of pain all over her ankle and there is moderate swelling in that area. Her XR is shown below 1. When would you XR an ankle? Are there any rules you would use? 2. Describe her XR 3. How would you manage this case? Case 2 A 9-‐month-‐old boy presents to ED with his mother as she noticed some swelling in his R thigh and he seemed to be unsettled. His XR is shown below 1. Describe this XR 2. What are your concerns with this image? 3. How will this case be managed?


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Febrile Neonate

Case 1 A 6-‐week-‐old girl is bought into emergency with her parents as she had a fever at home measured at 38.1 degrees. She has also been quite unsettled today and doesn’t seem to be latching to the breast as normal. 1. What further history would you like to know about this child, the pregnancy and

delivery? 2. What features on history and exam are suggestive of a serious illness in a

neonate? 3. How would you measure the temperature in a neonate? What gives you the

most accurate recording? The temperature is recorded in ED as 38.4, HR 164, RR 40, CRT 2-‐3 seconds. The baby’s skin appearance is shown below

4. Comment on the image above


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5. What investigations does this baby require? And how are you going to perform

them? What will you write on the request form? 6. You have performed a full septic screen and decide to start antibiotics, which

antibiotics will you choose and what are the doses? 7. When will you use acyclovir and what dose would you use? The LP results are back and shown below Test Result WCC 470 x 106/L (<106/L) RCC 0 Protein 1.6 g/L (0.2-‐0.2g/L) Glucose 1.4mmol/L (>2.5mmol/L) 8. What is your interpretation of the results? 9. What organisms are you concerned about in the child under 2 months old?


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Neonatal Jaundice

A term, 6-‐day-‐old baby presents to ED, having been sent in by the home midwife with poor feeding and jaundice. 1. What further questions would you like to ask in the history and what features

will you look for on examination specific to this case? 2. If this baby is breast fed, how might you assess how well it is feeding?

3. You recognize that maybe this baby is not feeding enough. Birth weight was 3.4Kg and Current weight is 3.1Kg. How might you supplement feeds, remembering it is important to account for parental wishes?

4. What investigations does this baby need? 5. How will you take its blood, can you describe this procedure? 6. What are the causes of jaundice in a neonate?


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Queensland Maternity and Neonatal Clinical Guideline: Neonatal jaundice

Refer to online version, destroy printed copies after use Page 29 of 35

Appendix B: Neonatal jaundice treatment graphs These example forms require approval for use by local health service.

The blood results are shown below Hb 152, WCC 18, Reticulocytes < 2% Bilirubin 360mmol/L 7. Can you plot the bilirubin on the below table and explain your management and

disposition of this baby?


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The Normal Neonate

For each of the images below describe what you see and the diagnosis


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Seizures Case 1 A 4-‐year-‐old boy presents to ED with his grandma after having a shaking episode at home. He has had a runny nose last night and been kept away from daycare today for the same. The episode occurred shortly after he woke from sleep and his grandma describes he felt hot prior to it starting. He shook for around 90 seconds but stopped before QAS arrived. His temperature with QAS was 38.1. 1. What questions in the history would help you to determine whether this was a

seizure? 2. What type of seizure is this likely to be and what age group do they occur in? He is febrile in ED but this resolves after ibuprofen. He otherwise has an unremarkable examination with no focal signs of illness. He now appears well and is sat up in bed playing 2 hours after the initial presentation. 3. Would you perform any further investigations? 4. What is your likely disposition? 5. What advice will you give to his parents on discharge? They are keen to know

how to manage a similar event and whether this means he has epilepsy.


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Case 2 A 7-‐year-‐old girl with known epilepsy presents via QAS after having a seizure at school. It was described as a tonic-‐clonic seizure, which is in keeping with her normal seizure pattern. The school administered intranasal midazolam, which resolved the seizure. 1. What factors or precipitants could increase the chance of her having a seizure? 2. She returns to normal within 30mins and mum arrives and states she missed her

morning medications, would you do any further investigations? And what is her likely disposition?

Minutes prior to them leaving the department she begins to seize, it is again consistent with a tonic-‐clonic seizure 3. What are your immediate management priorities and what would be your first

choice drug? 4. She continues to seize despite your initial management, what would you

consider next? 5. Her seizure resolves after administration of your choice drug and she returns to

her normal self after around 30 minutes, mum is keen to take her home. What is the best disposition for her at this point?


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Diabetic Ketoacidosis

Case 1 A 20kg, 6-‐year-‐old girl presents to the Emergency department with a 2-‐day history of lethargy and abdominal pain. She had 3 vomits this morning and is unable to keep anything down. On further questioning you discover she has had increased thirst and bed wetting, which is new over the last 2 weeks. The nurse at triage does a BSL and it reads high. 1. What do you expect this girl will look like in the bed and what are the likely

abnormalities in her observations? You decide to place an IV line and take a venous gas, the results are below: pH 7.15 pO2 100 pCO2 26 HCO3 18 Na+ 132 K+ 5.0 BSL 36 mmol/L Ketones 6.2 2. Can you interpret the gas above? Her observations are as follows HR 130 RR 42 Sats 99% RA Temp 36.4 CRT < 2 secs 3. What are your immediate management priorities?


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Appendix 2 – Fluid therapy calculation for children with DKA

Body weight in kg: ................................................... ❶ kg Total fluid bolus given ............................................... ❷ mL Deficit – fluid bolus already given (given over 48hrs) No signs of dehydration (tolerating fluids orally) Continue with oral rehydration Moderate 5% Dry mucous membranes, reduced skin turgor 50 mL/kg Severe 8% Above with sunken eyes & poor capillary return 80 mL/kg Shock severely ill, thready pulse, poor perfusion 10 mL/kg stat Enter deficit estimate (mL/kg) ................................ ❸ mL/kg Calculate total deficit: Multiply ❶ by ❸ ................ ❹ mL If fluid bolus was given: then subtract ❷ from ❹ ............................ ❺ mL Divide deficit over 48hr (divide ❺ by 48) ... ❻ mL/hr Note: Deficit given over 72 hours if Na+ corrected > 150 mmol/L or hyperosmolality > 310mosm/L Maintenance Fluids Weight: First 10kg 4 mL/kg/hr Second 10kg 2 mL/kg/hr Every kg after 20kg 1 mL/kg/hr Total maintenance fluids........................................ ❼ mL/hr Calculate total hourly fluid rate: add ❻ and ❼ mL/hr

CHQ-GDL-00706 - Diabetic Ketoacidosis: Emergency Management in Children

- 18 -

4. You decide not to give a fluid bolus but estimate 5% dehydration, using the table below calculate her fluid replacement

5. An hour after starting the Iv fluids her BSL is 32 and Ketones are 6.1, what is the next step in your management? How would you prescribe this?

6. You continue to check hourly blood gases and ketones and 2 hours later the BSL

is 11 and the Ketones are 3.6, how would your change your existing management?

7. What are the complications of DKA and the treatment of DKA to look out for?


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Hypoglycaemia Case 1 An 18-‐month old girl presents to ED with a viral illness for the last 3 days, last night she had one vomit and would not take her usual nighttime bottle. This morning she appears very lethargic and disinterested in food. The triage nurse decides to do a BSL, which reveals a BSL of 2.3 and Ketones of 7.1 1. What is the definition of hypoglycaemia? 2. What is your immediate management priority? 3. You insert an IV cannula, what bloods will you send to the lab? 4. Are there any other investigations you might consider? 5. Following your initial treatment she is more much alert and you admit her to

SSU, what would be your ongoing choice of fluid therapy and how might you deliver this?

6. Will you continue to check her BSL once in SSU? 7. How will you decide when she is ready to be discharged, what advice will you

give to her parents and what follow up will you arrange?


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Cardiac Presentations

Case 1 A 6-‐week old male presents with his parents as he appears to be getting increasingly SOB over the last week. On further history he was born term with no complications and although has always seemed to breathe a little fast it is getting much worse. 1. What other questions would you ask in the history to help determine the cause

of his presentation? 2. What would your differential diagnoses include? His current observations are HR 170, RR 74, Temp 36.2, Sats 96% , CRT < 2 secs 3. Comment on the observations. What else would you look for on examination to

help determine the cause of his presentation? He remains tachypnoeic and you decide to perform a CXR 4. Describe the CXR and the likely cause of his presentation? 5. What is the most common childhood congenital heart lesion?


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Case 2 A 3-‐day-‐old baby presents to the Emergency 24 hours after discharge from the maternity ward. He is pale, sweaty and not feeding well. As the nurse applies monitoring you notice his HR is 230. His ECG is shown below. 1. Describe the ECG and the most likely diagnosis 2. What maneuvers might you try as your first line of management? Hoe could you

perform these in a neonate? 3. The initial maneuvers don’t seem to improve the rate; you have an IV line in situ

so decide to attempt pharmacological therapy. What drug and dose would you use and how would you administer this?

4. This baby remains in the same rhythm despite all therapy to date and you decide

to cardiovert him. Describe how you would set up for this and the number of joules you would use.


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Eating Disorders Case 1 A 15-‐year-‐old female presents with her mother, as she is concerned that her daughter is losing weight and is nauseous all the time. Over the last 6 months she has lost 6Kg and now weighs 49Kg and is 166cm tall. 1. Although you are suspicious of an eating disorder her mother is very concerned

that there is an organic pathology. What other differentials would you need to consider and rule out?

2. What questions could you ask in your history to identify abnormal thinking about

weight, body image, diet and exercise? 3. What would you be looking for specifically in her observations and on

examination to suggest an eating disorder? 4. You feel she is high risk for an eating disorder and decide to do some blood tests,

what tests would you perform and why? 5. What are the admission criteria for a medical admission to manage eating

disorders?


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An ECG is taken as part of her work up and shown below: 6. Describe the ECG and what this will mean for her management 7. Her blood test returns and her potassium is 2.1, how will you manage this?

8. This young lady meets admission criteria for a medical admission but her mother decides she disagrees and wants to take her home, how would you manage this situation?


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Rashes

Describe and diagnose the following rashes then discuss your management 1. A 3-‐year-‐old girl was running around outside then started to get an itchy rash so

ran inside to her mother. The rash was widespread across her face and trunk and very itchy.

2. A 9-‐month-‐old boy, who is otherwise well in whom mum has noticed an itchy

rash on his hands and feet over the last week 3. A 7-‐year-‐old unimmunized boy presents with 2 days of fevers, coryza and an

itchy rash


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4. An 18-‐month-‐old boy presents with viral URTI and red lesions on his hands and mouth.

5. A 14-‐month-‐old boy who has been on antibiotics for a viral URTI and developed

an unusual rash

6. A 4-‐month-‐old boy who is unwell, febrile and has a red painful rash


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7. A 19-‐month-‐old girl with red lesions and yellow crusting over his face and R arm

8. A 14-‐year-‐old unimmunized boy presents with 2/7 high fevers, coryza, conjunctivitis and a widespread rash

9. A 14-‐month-‐old baby with a history of egg allergy and viral wheeze presents with a rash which he has had for 2 months but has gotten worse in the last 2 days


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References and Resources

Images obtained from • www.radiopaedia.org • www.nhs.uk • www.rch.org.au

Further resources

• www.spottingthesickchild.com • CHQ Guidelines on ED Dragon and www.tpched.org • Royal Children’s Hospital Melbourne Clinical Guidelines www.rch.org.au

This workbook is for use at The Prince Charles Hospital Emergency Department only


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