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49 Cards in this Set

  • Front
  • Back

When is fever an emergency?

Not all children with a fever need to be seen immediately (one exception being infants youngerthan 6-8 weeks of age).



So determine the level of severity

How to assess severity of illness?

Determine if:



  • If the individual (child or adult) is still perfusing major organ systems: the brain, skin, kidneys andlungs; and
  • If the individual has any underlying conditions (e.g., sickle cell disease, HIV, neutropenia,diabetes mellitus) that place the person at risk.

What emergency conditions cause altered mental status?


  • hypoxia
  • shock
  • hypoglycemia
  • poisoning

Conditions that can lead to acidosis and/or shock include what?


  • intussusception
  • sepsis
  • DKA
  • renal failure

CNS problems can also cause altered mental status

CNS causes of altered mental status?


  • Seizures
  • Tumour
  • Subarachnoid hemorrhage
  • meningitis
  • trauma

Seizures

generalized

Tumour

increased ICP due to mass effect


progressive behavioural changes

Subarachnoid hemorrhage

severe headache


altered mental status

Meningitis

increased ICP


decreased responsiveness

Trauma

child abuse


shaken baby syndrome


may lead to intracranial bleeds

Physical exam findings in bacterial meningitis?

neck stiffness


fever


altered mental status


Kernig or Brudzinski's sign

What is shock?

inadequate delivery of substrates and oxygen to meet metabolic needs of tissue

What are compensatory mechanisms to shock in children?


  • increased heart rate
  • increased systemic vascular resistance
  • increased heart contractility
  • increased venous tone
  • increased respiratory rate, tachypnea

Types of shock?


  • distributive
  • hypovolemic
  • cardiogenic
  • septic

Distributive shock?

hypovolemia caused by:VasodilationIncreased capillary permeabilityThird-space fluid losses

Hypovolemic shock?

Most common?


Mental status changesTachypneaTachycardiaHypotensionCool extremitiesOliguria

Cardiogenic

Associated with: Severe congenital heart diseaseDysrhythmiasCardiomyopathyTamponade




Signs/symptoms: Cool extremitiesDelayed capillary refill (> 2 seconds)HypotensionTachypneaIncreasing obtundationDecreased urine output

Septic shock?

Warm extremitiesBounding pulsesTachycardiaTachypneaAdequate urinationMild metabolic acidosis

Antibiotic treatment of meningoccemia?

Pen G


250,000 to 300,000 units/kg/day

Guidelines for prophylaxis of meningococcus

in adults, cipro is drug of choice




Prophylaxis is also recommended for those health care workers who had intimate exposure (suchas occurs with unprotected mouth-to-mouth resuscitation, intubation, or suctioning beforeantibiotics are administered).

MCV4 conjugate vaccine?

For the general population, the MCV4 is given to children ages 11-18.

Meningococcal conjugate vaccine

Morbidity and mortality of meningococcal disease?

Fatality rate: All ages: 10-15%


Adolescents: 21%

Complications of meningococcal disease?

  • Hearing loss
  • Neurologic disability
  • Digit or limb amputations
  • Skin scarring

What is the purpose of CABs?

To make sure you never miss a patient whose oxygenation or perfusion might be compromised,and2. To be structured in your exam so that you always first check for life-threatening problems thatmust be treated immediately.

How to assess circulation?


  • heart rate
  • capillary refill
  • BP


How to assess breathing?

describe effort and rate of breathing


listen to how patients lung sound


check patient's oxygenation

How is breathing assessment done?

Look at the chest to determine and record the respiratory rate,Listen to breath sounds for wheezes, rales, rhonchi, diminished breath sounds(pneumothorax, effusion, etc.), andUse a pulse oximeter to rapidly assess the oxygenation of the patient

How to open the airway

position neck


perform jaw thrust

What is D?

neuro assessment


check for hypoglycemia

DDx of lethargy?

  • Sepsis
  • Meningitis
  • Encephalitis
  • Toxic ingestion
  • Pneumonia C
  • NS tumor
  • Diabetic ketoacidosis (DKA)
  • Hypoglycemia
  • Renal failure

Sepsis

The combination of fever, lethargy, tachypnea, and decreased urination points to sepsis, oreven septic shock

Meningitis

Hallmark symptoms of meningitis are fever, headache, stiff neck, altered mental status, andphotophobia, although many patients present with only two or three of these clinicalindicators.

Encephilitis

Encephalitis is often caused by viral infections in children, and presents with altered mentalstatus and fever.

Toxic ingestion

Overdoses (toxic ingestion) often cause otherwise unexplained lethargy.Depending on the toxin, decreased urine output, rash, and tachypnea may be seen.

Pneumonia

Fever and tachypnea are found with pneumoniaAltered mental status would be uncommon unless the patient was severely hypoxic.

CNS tumour

Increased intracranial pressure from a CNS tumor may lead to lethargy and tachypnea

DKA

lethargy


tachypnea

Hypoglycemia

Hypoglycemia is a cause of lethargy or altered mental status.

Renal failure

Decreased urine output points strongly toward renal failure.An associated acidosis could lead to tachypnea and lethargy.

DDx of fever and petechiae

  • Meningococcal sepsis
  • Kawasaki disease
  • Toxic shock syndrome
  • RockyMountain spotted fever (RMSF)
  • Scarlet fever

Meningococcal sepsis

Whenever a patient presents with fever and petechiae, this diagnosis must always be at thetop of the list.This is true even if the patient otherwise looks well.A blood culture must always be done and antibiotics must always be given until the diseasecan be definitely ruled out.

Kawasaki disease

fever and rash



  • A "strawberry" tongue
  • Dry, red, cracked lips
  • Diffuse erythema of the oral cavity
  • Erythema and/or edema of hands/feet
  • A polymorphic truncal rash

Toxic shock syndrome

Toxic shock syndrome causes fever and a sunburn-looking rash that might feel rough to thetouch (like sandpaper).

RMSF

fever and petechiae as well.

The petechiae tend to be on the palms and soles.RMSF is epidemiologically less likely than meningococcus unless in an endemic area.

Scarlet fever

Rash appears on the upper trunk 12-48 hours after the onset of fever.As the exanthem spreads to the extremities, it become confluent and feels like sandpaper.It fades in 4-5 days and is followed by desquamation of the skin.Linear petechiae are evident in body folds and are called Pastia's sign.The pharynx is beefy red and the tongue is initially white and rough (strawberry tongue);within 4-5 days the white coating sloughs off and the tongue becomes bright red.

Managing fluids in shock?


  • maintain perfusion
  • fluid replacement with isotonic solutions, e.g. normal saline
  • true even if patient has relative contraindications
  • when patient no longer in shock, fluid restriction may be instituted

When to use intraosseous access?

Placement of an intraosseous line is easy and fast, and this type of line may be used to administerany fluid.If a peripheral intravenous line cannot be placed within 90 seconds, an intraosseous line is thefastest way to get access.

Fluids management in septic shock?

A patient with septic shock often needs repeated boluses of fluid. Give as much fluid as isneeded to attain perfusion.After a certain point, you may need inotropes to enhance cardiac contractility andvasopressors to raise the blood pressure by vasoconstricting the vessels. Epinephrine anddopamine are acceptable choices.

Pre-renal failure


  • underperfusion of kidneys secondary to shock can cause pre renal failure
  • common to misinterpret an elevated BUN and creatinine in this situation