Category Archives: Emergency medicine

BTS/SIGN Asthma guidance

Latest revision 2019.

Diagnosis is about probability – high probability is recurrent episodes, documented wheeze, atopic history, documented variable PEF or FEV1. Start treatment, “typically” 6 weeks inhaled corticosteroids (ICS). If good response to treatment, then diagnosis is confirmed.

If intermediate probability then spirometry with reversibility is preferred initial test for children old enough to do it (Grade D recommendation). If spirometry normal, then do challenge tests and/or FeNO measurement. For younger children, watchful waiting or trial of treatment.

Red flags –

  • Focal chest signs
  • Abnormal voice or cry
  • Failure to thrive
  • Vomiting
  • Wet/productive cough
  • Nasal polyps

Management

Self management education, written personalized plan.

Ask specifically about medication use and assess prescriptions. Explore attitudes to medication as well as practical barriers to adherence.

Not for routine house dust mite avoidance measures. Avoid smoking and second hand smoke.

Weight loss (including dietary and exercise programmes) for overweight and obese. Breathing exercise programmes can be offered as an adjuvant to pharmacological treatment.

Treatment

ICS are recommended preventer. Give twice daily until good control established.

5yrs and over, if add-on is required then choice between inhaled long acting beta agonist (LABA) or leukotriene receptor antagonist (LTRA). Only then increase dose of ICS from very low to low.

For exercise induced symptoms, generally just a sign that inadequate control! But if otherwise well controlled then give inhaled short acting beta agonist immediately prior to exercise. Then choice between LRTA, LABA, cromoglicate or theophylline.

Acute Severe Asthma

  • Sats under 92%
  • PEF 33-50% of best or predicted
  • Can’t complete sentences in one breath, or too breathless to feed
  • HR >140 (under 5), >125 (over 5)
  • RR>40 (under 5), >30 (over 5)

Life threatening defined as:

  • PEF <33%
  • Exhaustion, poor resp effort [tautology?]
  • Hypotension
  • Cyanosis
  • Silent chest
  • Confusion

Treat –

  • Oxygen
  • MDI plus spacer if mild/moderate
  • If refractory to beta agonist, add ipratropium 250mcg mixed into beta agonist [same dose for everyone]
  • “Consider adding 150mg magnesium sulphate to each neb in first hour if symptoms started <6hrs and presenting with sats <92%” [Recommendation based on MAGNETIC trial – no overall benefit but better Asthma Severity Score at 1 hour for this subgroup – see below] – 2.5ml of 250mmol/ml (1000mg made up to 16ml)
  • Give oral steroids early, dose by age.

Second line treatment –

  • Consider single IV bolus of salbutamol (15mcg/kg over 10mins)
  • Consider aminophylline for severe asthma unresponsive to maximal doses of bronchodilators and steroids.
  • Consider IV MgSO4 40mg/kg/d

Poor evidence for Neb magnesium in children or adults, limited evidence for IV. Systematic review in children (2018) – pulmonary function improved, hospitalization and further treatment decreased. No such evidence for Nebs.

Seizures

Seizures, fits, funny turns, convulsions, attacks…  None of these really has a medical meaning.  Convulsion suggests rhythmic motor activity, but that’s about it.  The implication of all of these is that there is excessive abnormal muscle contraction, usually bilateral.  Can be sustained or interrupted.

Nottingham RCPCH approved guideline distinguishes:

  • Febrile?
  • Already on anti-epileptic medication?  Consider checking levels, or at least storing sample.
  • Predisposing conditions? eg neurodevelopmental problem, brain injury/surgery.
  • Neonate or young infant? Some additional possibilities eg hypoxic ischaemic encephalopathy (HIE), Fifth day fits, drug withdrawal (neonatal abstinence syndrome), pyridoxine dependent epilepsy.

Most commonly Febrile convulsions ie age related, benign.  Beware complex (multiple seizures in same illness, focal features, prolonged >15 mins) and any abnormal findings eg neck stiffness, bulging fontanelle, prolonged illness, abnormal cognition before/after.

Important differentials are:

  • meningitis
  • encephalitis
  • shaken baby (non-accidental injury)
  • brain tumour/haemorrhage, hydrocephalus
  • ingestion (deliberate or accidental)
  • metabolic (low glucose, calcium/magnesium, low/high sodium)

May represent first evidence of epilepsy.

Accidental Adrenaline self-injection

eg with Epipen or Emerade.

Causes vasoconstriction with potential for gangrene.

Try:

  • warm water immersion
  • local nitroglycerin paste
  • subcut infiltration with a mixture of 1.5mg of phentolamine, 1mL of 2% lidocaine (at site and along course of digital arteries)

[advised by National Poisons Information Service]

n=365 adrenaline injections to hand, 213 to digit.  No cases with clinically apparent systemic effects, only a few patients had ischemia. No patient was admitted or had surgery. [Annals of Emergency Medicine. 56(3):270-4, 2010 Sep. PMID: 20346537]

Paediatric Sepsis 6

Consider sepsis or septic shock if a child has a suspected or proven infection and has at least 2 of the following:

  • Core temperature <36°C or >38.5°C
  • Inappropriate tachycardia (according to local criteria or advanced paediatric life support guidance)
  • Altered mental state (e.g., sleepiness, irritability, lethargy, floppiness, decreased conscious level)
  • Reduced peripheral perfusion or prolonged capillary refill.

If in doubt, seek an experienced opinion!

Within 1 hour of presentation, sepsis should be treated with:

  • Supplemental oxygen
  • IV (or IO) access – within 5 minutes of presentation – and blood tests including blood cultures, blood glucose,  and blood gas.
    • FBC, serum lactate, and CRP should also be ordered for baseline assessment.
    • Low blood glucose should be treated
  • IV or IO antibiotics should be given with broad-spectrum cover as per local policies.
  • Fluid resuscitation should be considered – aim to restore normal circulating volume and physiological parameters. Isotonic fluid (20 mL/kg) should be titrated over 5 minutes and repeated as necessary.
    • Beware fluid overload – look for crepitations and hepatomegaly.
  • Experienced senior clinicians or specialists should be involved and consulted early.
  • Inotropes should be considered early if normal physiological parameters are not restored after giving ≥40 mL/kg of fluids. It is important to note that adrenaline (epinephrine) or dopamine may be given via peripheral IV or IO access.

UK Sepsis Trust have Red Flag screening & action tool –

Start Sepsis6 pathway if ONE red flag:

  • objective change in behaviour or mental state
  • Unrousable or won’t stay awake
  • Looks very ill to HCP
  • Sats under 90% or new need for oxygen
  • Severe tachypnoea
  • Severe tachycardia
  • Bradycardia
  • Not passed urine in last 18h
  • Mottled, ashen or blue skin, lips or tongue
  • Non-blanching rash

Otherwise, any amber flags:

  • Behaving abnormally, not wanting to play
  • Significantly decreased activity/parental concern
  • Sats under 90^% or moderate tachypnoea
  • Moderate tachycardia
  • CRT >=3secs
  • Reduced urine output
  • leg pain
  • Cold feet/hands
  • Immunocompromise

If 2 then do bloods, consider if just 1.  Review by ST4 within 1 hour.

If lactate >2 then start Sepsis6

Diabetic Ketoacidosis

DKA – Updated NICE guidance 2016.

The potentially serious acute complication of diabetes.  In the absence of adequate insulin, glucose levels start to rise in the blood, spilling over the threshold for kidney resorption and causing a diuresis.  Metabolism switches to ketone bodies, causing acidosis.

There is no fixed definition. One guideline says pH <7.11 (about 73), bicarbonate under 18.

Beware can develop with normal glucose levels IN THOSE TAKING INSULIN.  Suspect if blood ketones above 3 in known diabetic, refer to hospital.  Between 0.5 and 3, follow sick day rules.

Rehydration should only be attempted by experienced paediatric teams!  Estimate fluid deficit on basis of blood pH – 7.1 or above, assume 5%, below 7.1 then 10%.

For maintenance, use 2ml/kg/hr for under 10kg; 1ml/kg/hr for 10-40kg; 40ml/hr for above that.

See graphic in BMJ 2016.

BSPED 2015 – Changes from previous guideline are as follows:

  1. Change in the degree of dehydration to be used to calculate fluids; 5% for mild to moderate DKA and 10% for severe DKA, based on pH
  2. De-emphasise sodium chloride bolus at the start of treatment apart from the sickest children
  3. No more than one 10ml/kg fluid bolus to be given without discussion with a senior doctor
  4. Further reduction in maintenance fluid rates, and simpler calculation of fluid rates
  5. No longer to subtract any boluses given up to 20 ml/kg from the fluid calculation (as the rate is already reduced significantly from previous guidelines)
  6. Continuation of 0.9% sodium chloride (instead of changing to 0.45% sodium chloride) for the full duration of rehydration
  7. Option for using an intravenous insulin infusion rate of 0.05 Units//kg/hour OR 0.1 Units/kg/hour

Sudden Unexpected Death in Infancy (SUDI)

Or Cot death?  Or SIDS (Sudden infant death syndrome)?

It is well recognised that some babies go to sleep apparently healthy, and then don’t wake up in the morning.  Even after a full post mortem (PM) investigation, no cause is found.  This unexplained phenomenon however has some very well recognised features eg age 2-6 months, prematurity, maternal smoking, poor socio-economic conditions, prone sleeping.

SUDI was originally defined by CESDI (Confidential Enquiry into Stillbirths and Deaths in Infancy) as death between 7 and 365 days where unexpected and unexplained at autopsy, during an acute illness that was not recognised as life-threatening, due to an acute illness of less than 24 h duration in a previously healthy infant (or death after this if life had only been prolonged by intensive medical care); definition also includes deaths from a pre-existing occult condition, and deaths from any form of accident, trauma or poisoning.

I find SUDI most useful for describing the initial situation one may find oneself in, particularly from the point of view of bereavement, need for medical and police investigation.  Interestingly, many of the same risk factors pertain to both deaths unexplained (ie SIDS, or strict SUDI) and to accidental deaths (with the exception of prone sleeping).

SIDS is the ICD recognized term, so is what is generally put on a death certificate.  However pathologists vary in their use of the terminology, some will use “Unascertained” to mean SIDS, others will use SIDS but reserve Unascertained for cases where there are additional factors that somehow cast doubt on the diagnosis.

Similarly, overlying (smothering) as a cause of SUDI is often inferred from the history, but may be specified on the death certificate to differentiate from SIDS.

PM finds a cause in about a 1/3 of cases) eg

  • Infection
  • Cardiomyopathy, anomalies of coronaries
  • Ion channelopathies
  • Metabolic disorders eg MCAD

See also Prevention, and Sudden unexpected postnatal collapse.

Sepsis

See also Sepsis6.

In reviews of child deaths, most significant recurrent avoidable factor is failure to recognize severe illness, most often at point of first contact with health services (Why children die, Pearson Arch Dis Child doi:10.1136/adc.2009.177071)

American College of critical care medicine 2007 shock update – central venous and arterial monitoring, dopamine within 15 mins, then warm vs cold shock, etc.  2009 Paed intensive care society audit in UK found majority of children (62%) targets were not met, for reasons that remain unclear. OR for death 3.8 where shock still present at time of PICU admission.

In 2011 goal directed therapy study, less intubations and inotropes, half the number of deaths. (But less severe group?) [Andrea Cruz, Pediatrics 2011;127;e758; DOI: 10.1542/peds.2010-2895]

Chinese study of antibiotic timing found reduced time to reversal of shock where given within 1 hour.

Definition of risk group – Paed CCM international consensus conference – at least 2 of the following 4, 1 must be abnormal temp (reported within 4 hours of admission if afebrile at presentation)

  • Core temp <36 or > 38.5
  • Tachycardia
  • Bradycardia
  • Tachypnoea
  • Leucocyte count elevated for age or >10% immature neutrophils

(Not clear why different criteria used for sepsis6)

Def of inappropriate tachycardia?

Management

  • Give high flow O2, regardless of sats!
  • Titrate fluids over 5-10 mins, repeat if necessary. Aim to reverse shock.
  • Early inotropic support viz adrenaline (make up during 3rd bolus). 0.3mg/kg in 50ml 5% dextrose, 1ml/hr (0.1mcg/kg/min)
  • 15 mins ideal, within 60mins acceptable.