Paediatric emergencies 2

Question 1

A 3yo boy is brought to ED with abdo. pain + vomiting. Parents report that he has been drinking + weeing a lot over the last few weeks and note a 3kg weight loss.

Describe key features you must assess for on examination given the likely diagnosis.

Answer 1

1. Breathing: ?Kussmaul breathing, ?ketotic breath
2. Fluid balance: ?dry mucous membranes, ?sunken eyes
3. Shock: HR, BP, CRT
4. Level of consciousness: ?drowsy, ?confused

Question 2

A 3yo boy is brought to ED with abdo. pain + vomiting. Parents report that he has been drinking + weeing a lot over the last few weeks and note a 3kg weight loss.

Which investigations would you perform given the likely diagnosis and what results would you expect?

Answer 2

Bedside tests:

1. capillary blood glucose: >11 mmol/L
2. near-patient ketone testing: >3 mmol/L
3. venous or capillary blood glucose: pH <7.3 or bicarb <15

Bloods:

1. glucose
2. U+Es

Question 3

A 3yo boy is brought to ED with suspected DKA. He is drowsy and clinically dehydrated but is not in shock.

How would you initially manage him?

Answer 3

1. 10ml/kg NaCl bolus IV over 60 mins
2. calculate fluid requirements and correct over 48hrs: (fluid deficit - bolus) + maintenance fluids. Use 0.9% NaCl with 40mmol K+/L
3. after fluids have been running 1-2 hrs: insulin infusion at 0.05-0.1 units/kg/hr

Question 4

How do you calculate fluid deficit in children presenting with DKA?

Answer 4

Fluid deficit = % dehydration x kg x 10

% dehydration:

• pH 7.2-7.29: 5% deficit
• pH 7.1-7.19: 7% deficit
• pH <7.1: 10% deficit

Question 5

What is the most common cause of death in children presenting with DKA? Which features should you look out for? How would you treat?

Answer 5

Cerebral oedema due to over rapid correction of fluid imbalance causing fluid shift back from ECF into ICF.

Early features: headache, irritability/agitation, unexpected decreased HR, increasing BP
Late features: deteriorating LoC, breathing pattern abnormalities, respiratory pauses, decreased SpO2. occulomotor n. palsies, abnormal posturing, pupillary inequalities/dilation

Treat with:

• hypertonic saline (2.7% NaCl) over 10-15 mins OR
• mannitol over 10-15 mins

Question 6

A 12yo boy is brought to ED by his parents after collapsing at home. On assessment he appears distressed with swelling of the lips, dyspnoea and a widespread urticarial rash. A wheeze is heard on auscultation. His BP is 90/65.

What would your initial Mx be?

Answer 6

Alert senior.

1. Adrenaline IM 0.01ml/kg of 1:1000 into mid lateral thigh
2. Nebulised salbutamol 5mg
3. Hydrocortisone IV 100mg
4. 0.9% NaCl IV bolus 20ml/kg

Regularly reassess. Repeat adrenaline IM up to twice 5-10 mins apart as required.

Question 7

A 6 yo girl (20kg) with a known history of epilepsy is brought into ED. She has been fitting for 5 mins and has not yet received any treatment. How should she be managed?

Answer 7

1. A-E assessment + establish IV access
2. high-flow O2
3. check BG
4. 2 mg lorazepam (0.1mg/kg) IV
5. after 10mins: repeat lorazepam 0.1mg/kg
6. after 10mins: 400mg phenytoin IV infusion (20mg/kg) or phenobarbitol IV
7. alert CICU for possible RSI (thipental sodium)

Question 8

A 12yo known diabetic is taken to ED. He is confused and has been vomiting. His BG is 2.6. How would you manage him?

Answer 8

1. If IV access: 10% dextrose (2mls/kg) IV
   If no IV access: IM glucagon 1mg (0.5mg in <8yo)
2. Recheck BG in 15mins
3. If required: 10% dextros3/0.9% Nal (5mg/kg/min)