Aims & objectives

2

Aims & objectives

Organ Emergency

Respiratory CroupBronchiolitisViral induced wheezeAsthma exacerbationEpiglottitis

Neurology Seizures

Gastroenterology and surgery

Pyloric stenosisIntussusception

Haematology ALLSickle cell crisis

Infection MeningitisSepsis

Other AnaphylaxisKawasaki disease

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Case-based discussion: 1

HistoryA 7-year-old child is rushed into the emergencydepartment by his mother. He is breathing heavilyand struggling to complete sentences in onebreath. He appears drowsy and confused. Thepatient has a history of asthma.

On examination, you note intercostal recessionsand a generalized wheeze. His PEFR is 39% of hisbaseline.

ObservationsHR 126, RR 35, SpO2 89%, Temp 38.1

(HR: 70-110)(RR: 20-25)

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Question: 1

5


HistoryA 7-year-old child is rushed into the emergencydepartment by his mother. He is breathing heavilyand struggling to complete sentences in onebreath. He appears drowsy and confused. Thepatient has a history of asthma.



(HR: 70-110)(RR: 20-25)

Definition: airway bronchospasm and inflammation resulting in airway obstruction

Epidemiology• Asthma affects 11.6% children aged 6-7 (NICE)• 60,000 hospital admissions per year in the UK

Risk factors• Viral infection• Inhaled allergens• Exercise• Emotion• NSAIDs

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Introduction: Asthma Exacerbation

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Pathophysiology: Asthma Exacerbation

Inflammatory response is driven by T-helper type 2 (Th2-cells)

1. Bronchial inflammation and bronchospasm• Terminal bronchioles

2. Bronchial obstruction • Increased mucous production and mucosal

oedema• Bronchospasm • Smooth muscle hypertrophy

3. Bronchial hyperresponsiveness

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Clinical features

Symptoms Signs

Evidence of trigger Respiratory distress

Breathlessness Wheeze

Reduced feeding Exhaustion

Reduced GCS

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Moderate Severe Life-threatening

SpO2 ≥ 92% SpO2 < 92% SpO2 < 92% and any of:

No features of severe asthma Too breathless to talk or feed PEFR < 33% (aged >5)

Aged 2-5• HR > 140• RR > 40

Silent chest

Aged > 5 • HR > 125• RR > 30 • PEFR 33-50%

Poor respiratory effort

Use of accessory neck muscles Agitation

Exhaustion

Hypotension

Cyanosis

Confusion

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Investigations: Asthma ExacerbationBedside• PEFR

• Moderate: > 50%• Severe: 33-50%• Life-threatening: < 33%

Bloods• Blood gas: evidence of respiratory failure (type 1

or type 2)• Inflammatory markers: raised if there is an

infective trigger

Imaging• CXR: hyperexpansion and/or evidence of infection

(1)

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Question: 2

HistoryA 7-year-old child is rushed into the emergencydepartment by his mother. He is breathing heavilyand struggling to complete sentences in onebreath. The patient has a history of asthma.



(HR: 70-110)(RR: 18-30)

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Question: 3

HistoryA 7-year-old child is rushed into the emergencydepartment by his mother. He is breathing heavilyand struggling to complete sentences in onebreath. The patient has a history of asthma.



(HR: 70-110)(RR: 18-30)

13

Management: Asthma ExacerbationOxygen: aim for SpO2 ≥ 94%

Bronchodilators: inhaled or nebulised if hypoxic• Salbutamol +/- Ipratropium• BURST/back to back: 3 salbutamol nebulisers

and 1 ipratropium nebulsier

Corticosteroid• Prednisolone PO• Hydrocortisone IV if unable to tolerate

IV bronchodilation• MgSO4, Salbutamol, Aminophylline

Intubation and ventilation

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Differential diagnosis: Respiratory distress

Bronchiolitis Croup Viral induced wheeze

Asthma exacerbation

Pneumonia

< 1 year < 3 years < 5 years > 5 years Any age

• 9 day illness• RSV

• Barking cough • Parainfluenza

virus

• Wheeze• Generally well

in between episodes

• Wheeze• Symptomatic

between episodes

• Productive cough

• High fever• Crepitations

If the child requires admission:• Bloods including capillary blood gas• CXR

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HistoryA 6-week-old male presents with multiple episodesof projectile vomiting after feeding. You note avisible olive shaped mass in the abdomen. He hashad 2 wet nappies in the last 24 hours.

When observing him being fed in the emergencydepartment, he vomits 10 minutes later. He hasmottled skin and a capillary refill time of 3 seconds.


(HR 110-160)(RR 30-60)

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Question: 4

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HistoryA 6-week-old male presents with multiple episodesof projectile vomiting after feeding. You note avisible olive shaped mass in the abdomen. He hashad 2 wet nappies in the last 24 hours.

When observing him being fed in the emergencydepartment, he vomits 10 minutes later. He hasmottled skin and a capillary refill time of 3 seconds.


(HR 110-160)(RR 30-60)

Definition: hypertrophy of the pyloric smooth muscleof the stomach

Epidemiology• 2-4 per 1000 live births• More common in males

Risk factors• Age: 2-6 weeks of age• Male: 4x more common• First born• Family history• Caucasian• (Maternal macrolides)

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Introduction: Pyloric Stenosis

(2)

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HCl

K+Na+

(3)

Metabolic alkalosis• Loss of gastric acid (HCl)

Hypochloraemia• Loss of chloride ions (HCl)

Hypokalaemia• Loss of potassium ions• Hypovolaemia activates the renin-angiotensin-aldosterone

system à sodium reabsorption and potassium excretion

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Introduction: Pyloric Stenosis

(2)

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Clinical features

Symptoms Signs

Projectile non-bilious vomiting post-feed

Evidence of dehydration• Capillary refill time > 2s• Mottled skin • Dry mucous membranes• Sunken fontanelle

Reduced wet and dirty nappies Visible peristalsis

Poor weight gain Olive shaped mass in the upper abdomen

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Clinical features

(4)

23

Investigations: Pyloric stenosisBedside• Test feed: observe for vomit• Glucose

Bloods• Capillary blood gas: pH, Na, K, Cl, HCO3, lactate

• Hypochloraemic, hypokalaemic, metabolic alkalosis• Urea & electrolytes

Imaging• Abdominal USS: sensitivity 99%

• >3mm thickness of the pyloric muscle

(5)

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Management: Pyloric stenosisManagement• Supportive

• NBM and NG tube decompression:stomach decompression

• IV fluids: rehydration andreplacement of electrolytes

• Surgical• Ramstedt pyloromyotomy: incision

of the muscles of the pylorus

(6)

HistoryA 7-month-old child presents to the emergencydepartment with his mother. The child is lethargicand floppy. He is visibly very pale and has adistended abdomen. The mother reports the childhas been vomiting and has passed red colouredstool on a few occasions.

You note him drawing up his legs to his abdomenand start crying.


(HR 110-160)(RR 30-60)

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(7)

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Question: 5

HistoryA 7-month-old child presents to the emergencydepartment with his mother. The child is lethargicand floppy. He is visibly very pale and has adistended abdomen. The mother reports the childhas been vomiting and has passed red colouredstool on a few occasions.

You note him drawing up his legs to his abdomenand start crying.


(HR 110-160)(RR 30-60)

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(7)

Definition: telescoping of a proximal segment of bowel into a distal segment

Epidemiology• Rare: 30-100,000 infants• Most common in males

Aetiology• Lead-point hypothesis

Risk factors• Age: 6-18 months• Viral infection• Henoch-Schonlein purpura• Lymphoma

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Introduction: Intussusception

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Pathophysiology: Intussusception • Viral infection: hyperplasia of Peyer’s patches• Henoch-Schonlein purpura: submucosal

haematoma• Lymphoma

(8)

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Clinical features

Symptoms SignsColicky abdominal pain• Episodic crying and agitation• Drawing knees up to the chest

Abdominal mass

Bilious vomit Abdominal distention

Bloodstained stool: ‘redcurrant’ jelly Hypotension and tachycardia

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Clinical features

(7)

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Question: 6

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Investigations: Intussusception

Bedside• Glucose

Bloods• Capillary blood gas: raised lactate with

metabolic acidosis if bowel ischaemia• FBC: anaemia• Urea and electrolytes: dehydration and AKI

Imaging• Abdominal USS: diagnostic investigation• Contrast enema: diagnostic and therapeutic (9)

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Management: Intussusception

First line:• Resuscitation: ABCDE

• IV fluids and blood products may be needed• IV antibiotics: prevent abdominal sepsis• Radiological reduction: air or contrast

Second-line:• Surgery: resection may be needed

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Differential diagnoses: Vomiting

Bilious (green) Non-bilious

Intestinal obstruction• Volvulus• Intussusception• Hirschsprung's disease

Gastroesophageal reflux

Gastroenteritis Gastroenteritis

Necrotising enterocolitis Pyloric stenosis

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Top-decile question

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Top-decile question

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Recap

• The severity of an asthma exacerbation is dependent on the SpO2, PEFR, and clinical presentation

• Management of acute asthma is with oxygen, bronchodilators, and corticosteroids

• Pyloric stenosis presents in young infants around 6 weeks of age

• Non-bilious projectile vomiting post feeding is typical

• Management is surgical

• Intussusception is usually seen around 6 months of age

• In exams it will often be associated with red-currant stool

• Management is with air or contrast enema reduction

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References

1. Mikael Häggström.When using this image in external works, it may be cited as:Häggström, Mikael (2014). "Medical gallery of Mikael Häggström 2014". WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain.orBy Mikael Häggström, used with permission. / Public domain

2. Henry Vandyke Carter / Public domain

3. This SVG image was created by Medium69.Cette image SVG a été créée par Medium69.Please credit this : William Crochot / Public domain

4. Xxjamesxx / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

5. Dr Laughlin Dawes, wikicommons

6. Schuetdm / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

7. Amanda Slater from Coventry, West Midlands, UK / CC BY-SA (https://creativecommons.org/licenses/by-sa/2.0)

8. Olek Remesz (wiki-pl: Orem, commons: Orem) / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

9. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

All other images were made by BiteMedicine or under the basic license from Shutterstock and not suitable for redistribution

https://creativecommons.org/licenses/by-sa/3.0




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