Category Archives: Emergency medicine

Stroke in children

Emergency medicine, General paediatrics, Neurology

Rare but happens.

Differential:

Can be due to arterial or venous occlusion.  50:50 in kids cf adults (80% infarct). Haemorrhagic can be due to rupture into infarct.

Presents with focal signs, headache, seizures most commonly. Else dysphasia, vomiting!, confusion. Fever! Acute signs often lacking or fluctuant cf history!  FAST criteria only 78% sensitive. 

NIH stroke severity scale has paeds version. 

Risk factors

Black/Asian

Cardiac (esp surgery, right to left shunt)

Sickle cell – esp anaemia, acute chest syndrome, HbS or HbS/Beta thal

Thrombophilia

Liver/kidney disease (secondary prothrombotic tendency)

VZV within 1yr, enteroviruses, HIV.

Vasculitis – Moya Moya (peaks at 5-9yr else adulthood), SLE, other

Cocaine, glue.

Marfans, homocysteinuria, Fabry’s disease, Neurofibromatosis

Cancer, radiotherapy

Hypoglycaemia. 

Management

High flow O2, 10ml/kg saline 

Imaging within 1hr. 

BP – avoid high and low? Cf adults

Monitor for RICP

Treat with aspirin.

Tests

  • CTA/MRA at time of CT/MRI
  • Echo
  • (Transcranial doppler in sickle cell- via temporal bony window)
  • Hbopathy screen
  • Cholesterol
  • Lupus anticoagulant, Anti cardiolipin ab (ACLA), consider beta 2GP1
  • Homocysteine
  • Alpha galactosidase
  • Lipoprotein A – marker for CVS disease, genetic. 
[RCPCH guideline May 2017]

Arrhythmia

Cardiology, Emergency medicine, General paediatrics

See SVT.

Adenosine 150mcg/kg? 12yr 3mg

Broad complex SVT – just treat as VT.

Cardioversion

Remove oxygen tubing for shocks unless closed circuit.

Stand clear – look at top/middle/bottom!

IM/IN ketamine plus sedation for synchronised shock.

Synchronised shocks are 1 then 2 J/kg.

Sync button needs pressed for each shock – most machines immediately reset. Press and hold – needs time to sync and give shock.

Resuscitation

Emergency medicine, General paediatrics

UK Resuscitation council updates guidelines from time to time.

See also anaphylaxis (now 2 guidelines, basic and refractory) and arrhythmia.

Atropine not part of guideline – neonates 10mcg/kg (no minimum). Else 20mcg/kg min 100mcg. 

Out of hospital – Shout for help AND ask for an AED.  Sudden OOH collapse likely to be cardiac, even in a child – don’t wait till after rescuer breaths!

Compressions 100-120.min for both infants and children. One third depth of chest – 4cm infant, 5 child (6 adult). 1 finger breadth above xiphisternum to avoid organs. 

40% blood volume might be lost before hypotension appears…

5th centile for systolic BP is 70 at 1yr, 80 at 10, 90 at 15yr. 

Haemothorax might be picked up in B but don’t manage until C!

C – compartments of body incl long bones. 1:1 RCC:FFP

TXA – bolus, remember 2nd dose (or double bolus). 

Log roll can be missed if suspected spinal unless penetrating back wound suspected (or found on absorbent surface…)

ATMIST – age, time, 

Parents need a senior person who understands!

CT head might be better done at trauma centre…

Rhabdomyolysis

Emergency medicine, General paediatrics, Genetics

Muscle breakdown with release of products into blood stream that can cause acute renal failure.

Typically occurs with crush injuries, sometimes seen with extreme endurance sports.

Can be infectious.

Recurrent seen with fatty acid oxidation disorders and Lipin 1 mutations.

Lipin 1 mutations

Autosomal recessive – heterozygotes may have exercise induced muscle symptoms or be prone to drug induced myopathy.

Basal CK high but spikes to over 100 000 with decompensation (infection, exercise, anaesthetic).

Treat crises with carbohydrates/intralipid.

Trauma

Emergency medicine, General paediatrics, Surgical

Children are small adults, when it comes to trauma!

Mortality jumps when airway management instituted more than 45 mins after 999 call. (NICE) Mortality actually rare with isolated head (7%) and abdominal (20%) trauma. But jumps to 50% for multiple sites.

Beware head impact apnoea.

Collars not required as part of immobilisation in children. Cx spine trauma v rare. Manual in line stabilisation best if necessary. Extrication maybe?

Triage tool highlights who needs to go to trauma centre eg mangled limbs, penetrating or open trauma, mechanisms eg ejection from vehicle.  But always clinical judgement.

If “hot critical” then decide on transfer to tertiary centre within 8 minutes. Airway, catastrophic haemorrhage and move.

C-ABC is catastrophic haemorrhage first.

Access above and below diaphragm if possible. Blood first line if bleeding. 10ml/kg aliquots. 1:1:1 packed cells, FFP and platelets as able.

Tranexamic acid dose 15ml/kg (same as paracetamol!). See major haemorrhage protocol. No role for permissive hypotension in children.

Avoid over resuscitation with crystalloid.

Pelvic binder problematic if moves. Fixes greater trochanters and public symphysis.

AVPU – but specify pain response!

Head injury: 3% saline preferred. Aim for high MAP, with inotropes if necessary. GGC has guideline. Adrenaline preferred.

Agitated kid – persevere with getting them into scanner without anaesthetic! In Wishaw, induction best in theatre but would then need to go in lift!  Limited expertise with waking them up! Discuss with Scotstar, maybe move, maybe tube.

Log roll 90% out, 20% in? Conrad 2012

Traumatic cardiac arrest: in adults, evidence for aggressive treatment of reversible causes. Consensus is for bundle of simultaneous interventions (not all necessary for every case), prioritised ahead of CPR!

  • Haemorrhage control
  • ETT or equivalent
  • Bilat finger thoracostomies
  • Rapid volume replacement with warmed blood NOT thoracotomy or inotropes. Persistent low ETCO2 is poor prognostic sign.

Even if death declared out of hospital, should be admitted for after care.

NAI audit – 5.2% rate of suspected child abuse. 75% under 1 yr. Often major trauma, often severe brain injury.

Major Incident

Workload should be spread out. Over 12 should go to adults (unless lots of adults too). Walking wounded to non trauma centres. Try not to separate children from injured parents – who worst affected?

Hyperkalaemia

Emergency medicine, General paediatrics, Renal

Usually due to renal failure. Causes arrhythmia and death…

Treatment

  • Slow injection of calcium – note calcium chloride and gluconate both available so potential for confusion. Dose is 0.11 mmol/kg, to be given over 5–10 minutes, maximum 4.5 mmol (0.11 mmol/kg is equivalent to 0.5 mL/kg of calcium gluconate 10%). Repeat as necessary if ECG changes do not improve.
  • Bicarbonate indicated if hyperkalaemia due to acidosis or renal failure. 
  • Insulin/dextrose – 10ml/kg 10% dextrose (so 5x usual dose for hypoglycaemia!), plus 0.1u/kg insulin (max 10 units), give over 5 mins. Likely peak action at 30 mins.
  • Dialysis.
  • Hydrocortisone if suspected Addisons. 
  • ECG monitoring
  • Repeated salbutamol nebs

Frusemide and calcium resonium only for asymptomatic!

Transfusions

Emergency medicine, General paediatrics, Haem/Oncology

January 2022 – safety alert from MHRA/CMO regarding deaths where there was a delay in providing emergency transfusion.

Should be agreed criteria for rapid concessionary release of blood products.

One issue is Autoimmune haemolytic anaemia, where the presence of red cell antibodies will complicate cross matching (11% mortality!).

Another issue highlighted is failure to give Prothrombin complex concentrate to reverse warfarin (and some other anticoagulants) where severe or limb/sight threatening bleeding.

Legal Highs

Emergency medicine, General paediatrics

Legal highs now illegal! 

=“New psychoactive substances” – no penalty for possession. Generally multiple substances taken simultaneously. Previously sold as herbal incense or “bath salts”. Now online “party pills” etc. Packaging can remain the same but product changed. Mostly from China. 

Drug deaths in Scotland 3x higher than in UK as a whole, and higher than any other EU country. Since NPS are unidentifiable and typically multiple substances taken, it is hard to attribute specific deaths. 72% male. Synthetic Cannabinoids, cathinones (stimulant), phenethylamines (hallucinogenic), benzodiazepines. Can be smoked or ingested.

Toxbase has nicknames, but examples are Black mamba, Exodus, Damnation. 

Cannabinoids can cause tachycardia, long QT and hypokalaemia. For agitation avoid medication if possible else midazolam. Generally 6 hour effect. 

Cathinones snorted or injected as well. Euphoria, intense positive emotion. Dyspnoea, palpitations. Narrow complex arrhythmia. Trismus. Acidosis. Hyperpyrexia. Effects up to 24 hours. Check CK, coagulation, LFTs. 

To treat acidosis, treat everything else! Then phone Toxbase!

Phenylethylamines stimulant as above plus hallucinations. Coronary ischaemia, organ failure. 

Synthetic benzodiazepines tend to have pseudoscientific names. Flumazenil not used as risk of other drugs emerging to cause seizures etc. 

See Serotonin toxicity syndrome for hyperpyrexia, increased muscular activity, autonomic instability.

Meningococcal disease

Emergency medicine, General paediatrics, Infectious disease

Gram negative diplococci, causing meningitis and septicaemia. Sometimes bone/joint infection. Neisseria (not meningitidis) responsible for ophthalmia neonatorum.

Main serogroups:

  • A – responsible for epidemics of meningitis across “Meningitis belt” of Sub-Saharan Africa, until Men A monovalent vaccine introduced in 2010 (still epidemics, but due to other serotypes). Hajj also triggers outbreaks.
  • B – 4 component vaccine introduced in 2015 to deal with B being the most common cause of invasive meningococcal disease since introduction of MenC vaccine. Based on vaccine developed for New Zealand epidemic.
  • C – used to be most common cause of invasive meningococcal disease in UK until vaccine introduced. So successful that early dose was dropped from routine schedule, although later resurgence in older children and young people, so teenage booster and university catch up programme introduced.

Clinically, notorious for rapidly evolving, often fatal septicaemia with non blanching rash and limb ischaemia. Curiously, meningococcal meningitis, on the other hand, is the most benign of the various causes of bacterial meningitis. Can be mixed picture, ranging from a few petechial spots only with an otherwise typical meningitis presentation, or else meningococcal septicaemia with neck stiffness, where presence of meningitis is actually a good prognostic sign.

Exquisitely sensitive to antibiotics. Meningitis epidemics in Africa treated with single IM dose ceftriaxone!!! Nasal carriage is the reason for spread, so prophylaxis for close contacts important.