Identify and treat cause appropriately i.e admit to hospital if needs investigations, iv abx etc Simple regular antipyretics Encourage fluids Not advised to use cold sponging, fans as increases core temp (febrile convulsions – the rapid rate of rise not the actual number is the problem, 6/10 recur, slight increase risk epilepsy against background population)
Spotting the sick child - https//www.spottingthesickchild.com/fever/key- bacground-information/facts-and-figures/42 NICE quick reference guide May 2007 - Feverish illness in children (children under 5) http://www.nice.org.uk/nicemedia/live/11010/3052 4/30524.pdf
Age (e.g. <1yr bronchiolitis) Ex-prem (nicu etc) Parents definition of respiratory distress Apnoea, cyanosis Cough Pyrexia Noisy breathing (?new) Feeding (wet nappies) Fhx atopy (sleep, play disturbance) Admissions, steroids, intubated? If has inhalers, compliant? Also frequency when ill.
ABCDEFG as always! Alert and interested? Agitation or lethargy Posture (sitting up) Speech (if old enough), broken, triggers cough, hoarseness Noisy breathing – coryza, wheeze, stridor, grunting, strained crying RR – tachypnoeic (can be normal if periarrest), prolonged exp phase
Respiratory distress – nasal flaring, tracheal tug, recession - supraclavicular, sternal, intercostal and subcostal. Accessory muscle use - head bobbing and abdominal breathing. Sats & HR – 98-100%, needs O 2 if less than 95%, tachycardic (can be normal if periarrest). Auscultation (not as valuable as small chest so lots of transmitted sounds) wheeze, creps and air entry. PEFR is appropriate age and mild/mod.
Depends on cause if very unwell to hospital e.g needs O2, tiring or poor feeding Can try 5-10 puffs salbutamol via spacer, if needs more than 4hrly needs admission If facilities try nebuliser
Worry! Likely concerns? “Her bottom’s ever so red!” “His cousin’s had chickenpox and now he’s poorly with these little spots” “Her eczema’s got much worse, all crusty and weepy” “He just had some peanut butter then five minutes later he came out in this rash” “I’ve done the tumbler test!”
Common presentation Often benign – viral/fungal/allergic/eczema Approach Is the child sick? Could there be serious underlying disease? Who will manage them, where, when? Likely concerns Meningococcal septicaemia Anaphylaxis Toxic shock syndrome
General features – fever, rigors, conscious level, irritability, vomiting, breathing difficulty Feeding, nappies Evolution and distribution of rash; itchy? Associated symptoms: headache, photophobia, abdominal pain, joint pain, cough, conjunctivitis Unwell contacts? Exposure to known allergen? Recent illness or injury? Relevant past history – atopy? Food allergy? Immunisations?
1. ABCDEFG as always! 2. The rash itself Distribution Configuration Morphology
A sick child: lethargic or irritable, feverish, rigors, not feeding, joint pain, tense fontanelles. May not have signs of meningism. Then the rash: 1. non-specific erythema 2. petechial 3. purpuric Then cardiovascular collapse [pictures removed]
Neisseria meningitidis 2/100 000 Serogroup B 50% of cases: children <4y 85% of cases septicaemic:15-20% mortality Peak incidence: winter 1-2 cases per GP career
Suspected meningococcal disease: Parenteral abx + urgent transfer - 999 Give IM/IV benzylpenicillin: 300mg (<1y) / 600mg (1-9y) / 1.2g Withhold only if hx of anaphylaxis DO NOT DELAY TRANSFER FOR ABX [Suspected bacterial meningitis without non-blanching rash: Urgent transfer - 999 Parenteral abx only if anticipate significant delay in transfer]
A relatively well child has abdominal pain, joint pain and this rash: [pictures removed] What diagnosis are you considering?
Immune mediated necrotising vasculitis M>F Peak incidence 3-8y Which obs and bedside tests would you do? BP, urinalysis Admit? Pain management, renal assessment, intussusception
A completely well child with a petechial/purpuric rash [picture removed] Investigate? FBC: ?ITP (?leukaemia) Usually acute and transient in children Admit? Refer to paediatrician
History of exposure followed by life threatening hypersensitivity response A – angiooedema B – bronchospasm C – circulatory collapse Widespread rash usually present: urticarial erythematous combination
Unwell child with high fever, diarrhoea, recent hx of minor burn Burn may appear normal Widespread erythematous rash – sunburn like; later desquamates Admit? IV antibiotics
Miserable child Prodrome of fever, malaise, arthralgia Painful, itchy skin and mucosal lesions Not drinking Recent mycoplasma infection [pictures removed] Possible diagnosis? Stevens-Johnson Syndrome Admit? May need fluids, antibiotics
Irritable child with fever for 5d +… [pictures removed]
Febrile systemic vasculitis 30-70% untreated cases: coronary artery stenosis/aneurysm Risk of myocarditis and MI Admit? May need IV Ig in acute stage Aspirin
Identify and treat cause. If refusal e.g. secondary to tonsillitis, simple analgesia or difflam may be sufficient to encourage. Fluid challenge (diaraloyte, use syringe and record), if fails, admit for ng/iv fluids If DKA or metabolic condition, send A+E urgently as will need senior input
Worry! Guilty… Reasons for attending “he’s got a cut (big bump) on his head” “she whacked it really hard” “he was knocked out” “she’s not been right since it happened”
Common presentation to CED 300 000 CED attendances per year May or may not come via GP GP may have bigger role in after care Likely concerns Diffuse axonal injury Intracranial haemorrhage Skull fractures Vigilance for possible non-accidental injury
Witness account if possible Mechanism of injury: forces, height, surface, helmet; beware falls, RTAs LOC/amnesia Seizure
AVPU/GCS General behaviour – quiet vs persistently drowsy; upset vs irritable Focal neurology – pupil abnormalities, limb weakness.
Scalp: signs of skull fracture boggy haematoma, skull depression, Battle’s sign, panda eyes, bulging fontanelle, CSF otorhinorrhoea, haemotympanum superficial wounds Full exposure especially if concerned re NAI
Witnessed loss of consciousness > 5 mins Amnesia (antegrade or retrograde) > 5 mins Abnormal drowsiness 3 or more discrete episodes of vomiting Clinical suspicion of NAI Post-traumatic seizure but no history of epilepsy Age > 1 year: GCS < 14 Age < 1 year: GCS (paediatric) < 15
Suspect open/depressed skull or tense fontanelle Any sign of basal skull fracture Focal neurological deficit Age 5 cm Dangerous mechanism (high-speed RTA, fall from > 3 m, high-speed injury from projectile or an object) Any one of these in a child is an indication for a CT head (NICE CG56, September 2007)
Simple analgesia if indicated If any red flags: CED; consider 999 + NBM If well but concerned re NAI: refer to paediatrics Close & dress wounds if competent and if confident the injury is non-significant Safety netting, written advice if sending home
NICE clinical guideline CG56 - Head Injury September 2007 http://guidance.nice.org.uk/CG56 Spotting the sick child - https://www.spottingthesickchild.com/symptoms/head - injury/