Triad of:
Cool IV fluids, ice packs, bear hugger on cool, etc.
Benzodiazepines, PO/NG cyproheptadine.
RSI.
No role for antipyretics! No evidence for dantrolene. Avoid suxamethonium, fentanyl, alfentanil.
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.
Gram negative diplococci, causing meningitis and septicaemia. Sometimes bone/joint infection. Neisseria (not meningitidis) responsible for ophthalmia neonatorum.
Main serogroups:
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.
Latest revision 2025. See also asthma.
Diagnosis is about probability – high probability is recurrent episodes of cough, wheeze, breathlessness, chest tightness plus documented wheeze, atopic history, documented variable PEF or FEV1. Isolated episodic cough is not sufficient. Episodes typically triggered by viral infections, cold air, exertion, laughter or emotion. 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 Fractional exhaled nitric oxide (FeNO) measurement. For younger children, watchful waiting or trial of treatment [colour code suggests this is appropriate from age 1, but no advice given for under 1…].
FeNO has reasonable positive predictive value, but false positives in allergic rhinitis, rhinovirus and dietary nitrates, plus overlap in values between asthmatics and normal population (especially children).
Red flags –
Self management education, written personalized plan. Assess control – consider using Asthma Control Test (ACT) questionnaire or similar.
Assess risk of future attacks. Co-morbid atopic conditions, younger age, obesity, and exposure to environmental tobacco smoke are markers of increased risk (some of these strongly socioeconomically linked, of course).
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 for adults.
ICS are recommended preventer. An asthma attack in the previous 2 years, symptoms 3 days a week, or using reliever 3 days a week, or waking 1 night a week are indications. Give twice daily at least until good control established.
Start at dose appropriate for the severity of the disease. In mild to moderate asthma, no benefit in starting at high dose and weaning. In children, “reasonable” starting dose is Very Low (100mcg twice daily of Clenil or equivalent).
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 (100mcg Clenil or equivalent twice daily) to low (200mcg twice daily).
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.
Life threatening defined as:
Treat –
Second line treatment –
Systematic review of IV Magnesium in children (2018) – pulmonary function improved, hospitalization and further treatment decreased. MAGNETIC trial of Magnesium nebs did not show a clinically significant improvement in mean asthma severity scores in children with acute severe asthma. But better Asthma Severity Score at 1 hour where saturations <92% at presentation and those with preceding symptoms lasting less than 6 hours [Lancet 2013]. 2022 Metanalysis found no benefit but varying protocols and populations.
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 most of these is that there is excessive abnormal, involuntary muscle contraction, usually bilateral. But more broadly, some involuntary, usually sudden and self terminating episode of abnormal (or at least non-purposeful) activity and/or impaired awareness. Can be sustained or interrupted.
Nottingham RCPCH approved guideline distinguishes:
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:
May represent first evidence of epilepsy.
eg with Epipen or Emerade.
Causes vasoconstriction with potential for gangrene.
Try:
[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]
Consider sepsis or septic shock if a child has a suspected or proven infection and has at least 2 of the following:
If in doubt, seek an experienced opinion!
Within 1 hour of presentation, sepsis should be treated with:
UK Sepsis Trust have Red Flag screening & action tool –
Start Sepsis6 pathway if ONE red flag:
Otherwise, any amber flags:
If 2 then do bloods, consider if just 1. Review by ST4 within 1 hour.
If lactate >2 then start Sepsis6
DKA – BSPED guidance 2021.
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.
Presents with weight loss, tiredness, vomiting, heavy breathing (Kussmaul), reduced consciousness. Diabetes symptoms of course, if first presentation, which might just be new wetting, or unusually heavy nappies. Can be confused with pneumonia, or appendicitis! Often missed diagnosis. In 2020 Lanarkshire audit, half had seen GPs at least once before diagnosis, with many having had bloods done rather than BM, or being asked to hand in urine the next day… 40% had BM done by family member!
Traditionally 15-17% of new presentations of diabetes are DKA, but with pandemic went up to 66%
ISPAD def DKA = Bicarbonate pH under 7.3 (H+50) PLUS ketones 3+ (blood or urine).
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.
Mild (over 7.2 or 63) vs moderate (7.1-7.2 or 79) vs severe (79+) categories. Treat as 5 vs 7 vs 10% dehydrated respectively.
All get 10ml/kg over 30 mins (assuming you start IV fluids) unless shocked (10/kg over 15 mins, repeat up to 40 then inotropes).
Maintenance fluids (0.9% NaCl with 20mmol KCl per 500ml bag) as per traditional formula (Holliday-Segar method) – 100ml/kg/d for under 10kg; 50ml/kg/d additionally for each kilo between 10-20kg; 20ml/kg/d for each kilo above that.
See graphic in BMJ 2016.
If acidosis not correcting, check cannula, check fluid calculations, consider sepsis. Replace insulin syringe! Acidosis can also be caused by hyperchloraemia (hence Plasmalyte preferred at RHC – less chloride).
Risk of thromboembolism due to dehydration and immobility during recovery.
25% mortality from cerebral oedema, 34% long term neurodisability. Headache, irritability, agitation. Posturing, focal neurology eg eye movements, pupil asymmetry. Cushings triad – bradycardia, hypertension, breathing irregularity.
Hypertonic saline (2.7 or 3%, 2.5-5ml/kg over 10-15 mins) or mannitol (20%, 0.5-1g/kg over 15 mins), no preference.
Stay on DKA pathway (and not transfer to subcutaneous insulin) until:
Cytotoxic vs vasogenic (resistant to steroids) vs interstitial (obstruction eg meningitis – not steroids, ?osmotic) vs osmotic (CSF, ECF low osmo) vs hypertensive.
In DKA, there is a 25% mortality from cerebral oedema, 34% long term neurodisability.
Presents with headache, irritability, agitation (which can be difficult when child is unwell with something else). Then altered consciousness, posturing, focal neurology (check eye movements, pupils). Classically Cushing’s triad: hypertension, bradycardia, irregular breathing pattern.
Clinical diagnosis really. CT can show (better than MRI!).
Hypertonic saline (2.7 or 3%, 2.5-5ml/kg over 10-15 mins) or mannitol (20%, 0.5-1g/kg over 15 mins), some people prefer hypertonic saline but whatever is closest to hand! Frusemide adjunctive.
Consider Aciclovir if diagnosis unclear (in case herpes encephalitis – CT not great, LP can be non specific).
Brain protection = 30deg head up, midline position. Avoid hypotension. Avoid hypocapnia (intubate and ventilate if in doubt).
Hyponatraemia common – typically due to SIADH but treat any underlying cause, esp hypovolaemia.
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
See also Prevention, and Sudden unexpected postnatal collapse.