 Pyrexia  Dyspnoea  Rash  Abdominal pain  Dehydration  Head injury  Key history, exam, differentials, red flags and management

 Age - generally worried >39.5 except in <3m anything over 38 significant  Temperature (measured), pattern  Duration >5/7 ?Kawasakis etc  Behaviour ? Drowsy, irritable, poor feeding  Seizure? Description, duration, fhx  Risk factor - CP, prem, immunosuppressed, leukaemia  Improves after antipyretics?  Immunisations UTD?  Foreign travel, ill contacts, dodgy food  May have specific symptoms, cough, wheeze, sob, limp, joint pain but often non-specific compared to adults e.g. Irritable, poor feeding

 Airway  Breathing – tachypnoeic, rr, distress  Circulation – cap refill, cool peripheries, tachycardic, hypotension (late sign), murmur (may be flow)  Disability – AVPU, GCS, grizzly  Exposure and ENT – rashes, mottling, lymphadenopathy, tonsils, tongue, TMs, abdomen  Fluid and fontanelle – sunken eyes, skin turgor, mucous membranes, nappies, output  Glucose

 Persistent (5/7>)  Fever + 4 of: bilateral non-purulent conjunctivitis, cervical lymphadenopathy, membrane changes, erythema/desquamation ?Kawasaki  Meningism (neck pain, photophobia etc)  Joint pain (swelling, erythema, limp)  No obvious focus

 LRTI, pneumonia, croup, influenza  Tonsillitis, otitis media.  Kawasaki disease  Meningitis  UTI, pyelonephritis  Ostemyelitis, septic arthritis  Wound infections, abscesses  Gastroenteritis  NAI - cerebral bleeds can cause fever, irritablility

 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// bacground-information/facts-and-figures/42  NICE quick reference guide May Feverish illness in children (children under 5) 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 – %, 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.

 Choking  Apnoea  Status asthmaticus

 Bronchiolitis  Asthma  Croup  Pneumonia  Cardiac abnormality  etc

 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

 toms/difficulty-in-breathing/key- background-information/facts-and-figures/25

 Spotting the sick child - ficulty-in-breathing/key-background- information/facts-and-figures/25 ficulty-in-breathing/key-background- information/facts-and-figures/25  British Thoracic Society June 2011 Asthma Management /AsthmGuidelines/sign101%20June% pdf

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/ 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 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 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

999 IM adrenaline 1: y:150 mcg= 0.15mL 6-12y:300 mcg= 0.3mL >12y:500 mcg= 0.5mL

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

Symptoms/signs suggestive of:  Meningococcal septicaemia  Henoch-Schonlein Purpura  Idiopathic Thrombocytopaenic Purpura  Leukaemia  Anaphylaxis  Toxic shock syndrome  Stevens-Johnson syndrome  Kawasaki disease

 Viral  Fungal  Eczema  Allergic

 Approach  Depends on cause  Seek timely advice, referral or transfer +/- appropriate immediate management

 Spotting the Sick Child  NICE clinical guideline CG102 – bacterial meningitis and meningococcal septicaemia (under 16y) June  GP notebook -

TIME FOR A QUICK BREW FOLKS!

 Acute or chronic  SOCRATES  Vomiting ?bilious  Constipation, diarrhoea, bloody  Eating and drinking, appetite  Fever  Growth, failure to thrive  Disturbed sleep  Stress  Dysuria, frequency and back pain (not useful in young)  Ill contacts, dodgy food, foreign travel

 ABCDEFG as always!  Pallor  Hydration  Mass (faecal, Wilm’s etc)  Tenderness  Guarding  Bowel sounds  Peritonism  Genitalia, hernia, scrotal oedema  Do NOT do a PR

Signs of:  Peritonism  Intussuception (‘redcurrent jelly stool’)  Abdominal mass (?Wilm’s tumour)  Torsion of testes  Vomiting bile (?obstruction)

 Mesenteric adenitis  Appendicitis  Intussuception  Gastoenteritis  Tumour e.g Wilm’s  UTI  Torsion  Hernia  Anxiety

 Identify and treat cause appropriately  Simple analgesia  NBM if suspect surgical cause  Explore stress related issues if relevant

 Spotting the sick child – dominal-pain/key-background-information/facts-and- figures/87

 Vomiting when, bilious, blood, frequency, duration  Diarrhoea ?blood, frequency, duration  Abdominal pain  Polyuria, polydipsia  Systemically well ?drowsy  Intake, normal feeding, output, wet nappies  Weight loss  Ill contacts  Recent foreign travel, dodgy food  Consanguity

 ABCDEFG as always!  Hydration - sunken eyes, sunken fontanelle, reduced skin turgor, reduced output, dry mucous membranes  Cold peripheries, tachycardia, reduced cap refill, hypotension

Symptoms/signs of:  Pyloric stenosis (projectile vomiting)  DKA (urine dip, bm)  Hypernatraemic dehydration (neuro signs)  (Known) Inborn errors of metabolism  (known) chronic disease e.g. CF or have ileostomy

 Gastroenteritis/gastritis e.g. Rotavirus  UTI  URTI  Abdominal obstruction  DKA  Poor feeding technique  Pyloric stenosis  Refusal e.g tonsillitis  Inborn errors of metabolism

 toms/dehydration/key-background- information/facts-and-figures/81

 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

  Spotting the sick child – hydration/key-background-information/facts-and- figures/81

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 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

 Change in behaviour  Drowsiness/agitation  Headache  Vomiting  NAI risk factors Implausible MOI/vague hx/eye & ear injuries

 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 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  Spotting the sick child injury/