1. Family health diploma Pediatric lecture On importance of to check general danger signs.

2. Dr.Shazia Memon Associate Professor

3. Learning objectives Identify general danger signs. How to check the child for general danger signs Know the D/D of child with convulsion, lethargy or coma. To give pre referral treatment. Base line investigations.

4. A general danger sign is present if: The child is not able to drink or breast feed The child vomits every thing The child has had convulsions during current illness The child is lethargic or unconscious The child is convulsing now.

5. Assess For General Danger Sign Ask: Is the child not able to drink or feed? Does the child vomit every thing ? Has the child has convulsions? Look: See if the child is lethargic or unconscious. See if the child is convulsing now. CHECK FOR GENERAL DANGER SIGNS

6. WHEN YOU CHECK FOR GENERAL DANGER SIGNS ASK: Is the child not able to drink or breast feed? A child has the sign “not able to drink or breast feed” if he child is not able to suck or swallow when offered a drink or breast milk. Causes: CNS infections. Acute gastroentritis with severe dehydration. Sepsis Throat abscess

7. DOES THE CHILD VOMITS EVERY THING? A CHILD WHO IS NOT ABLE TO HOLD ANY THING DOWN AT ALL HAS THE SIGN ”VOMITS EVERY THING” CAUSES Lethargic/unconscious Acute gastroenteritis with severe dehydration Intestinal obstruction sepsis

8. HAS THE CHILD HAD CONVULSIONS ? CONVULSION: Paroxysmal, time limited change in motor activity and/or behaviour that results from abnormal electrical activity in the brain CAUSES: Causes In favour Meningitis History of high grade fever Recurrent history of otitismedia Neck stiffness Signs of meningial irritation Petachial rashes (meningiococal meningitis) Tense or bulging fontenelle Abnormal posture CSF suggestive of

9. Encephlitis Reccent history of gastroentritis Irritibility/behavioural changes Raised ICP Csf T.B meningitis Hx of contact with t.b patient Hx of weight loss Low grade fever Loss of appetite Focal neurologicalsigns Cranial nerve palsy Labs: CXR,Sputum AFB, montoux test, Febrile convulsions Age 6 months to 5 years High grade fever No loss of consciousness Positive family Hx Head trauma

10. Poisoning Hx of poison ingestion or drug over dose Hypertensive Encephalopathy Hx of head ache Vomiting Irritibility Raised blood pressure Diabetic ketoacidosis Hx of polydypsia, polyphagia, polyurea Hx of weight loss Acidotic breathing Labs: High blood sugar Urinary ketones

11. Dr. Shazia Memon Assistant professor

12. Learning objectives At end of session you become able to: Take relevant history. Know the D/D of child with convulsion or coma Know the out-patient management of child presenting with convulsion /coma and identify the pre referral treatment. know in-patient management of child presenting with convulsion /coma.

13. Learning objectives Following Skills you will learn during practical and clinical session To Identify general danger signs (practical /clinical) To Assess the level of consciousness by AVPU scale. To examine the child for signs of meningeal irritation To perform the motor system examination.

14. Why convulsion is selected as general danger sign. CONVULSION: Paroxysmal, time limited change in motor activity and/or behaviour that results from abnormal electrical activity in the brain. Convulsion is the presenting complaint in around 30% of children admitted in pediatric emergency If occur with underlying disease increases the risk of morbidity and mortality. If uncontrolled will lead to brain damage.

16. Common causes of convulsions CNS Infection Febrile convulsions Epileptic convulsions Metabolic. Hypoglycemia Head injury Intoxication (drug over dose) Hepatic encephalopathy DKA. AGN ( hypertensive encephalopathy. Most common causes are febrile convulsions and CNS infections.

17. Assessment areas Out-patient/ community management. Patient flow high. Screen the patient for any severe classification. Identify the pre-referral treatment. Give pre-referral treatment. Inpatient management. Initially assess the child in triage. Look for emergency /priority signs. Give emergency treatment. Admit the child.

18. Community or outpatient management History : check for general danger signs Ask for 5 main symptoms Fever with general danger or Stiff neck and enquire about malaria risk. Classify the illness. Identify and give pre-referral treatment. Write down the referral note. Refer the child to inpatient department.

19. Assess For General Danger Sign Ask: Is the child not able to drink or feed? Does the child vomit every thing ? Has the child has convulsions? Look: See if the child is lethargic or unconscious. See if the child is convulsing now. CHECK FOR GENERAL DANGER SIGNS

20. WHEN YOU CHECK FOR GENERAL DANGER SIGNS ASK: Is The Child Not Able To Drink Or Breast Feed? A child has the sign “not able to drink or breast feed” if he child is not able to suck or swallow when offered a drink or breast milk. DOES THE CHILD VOMITS EVERY THING? A CHILD WHO IS NOT ABLE TO HOLD ANY THING DOWN AT ALL HAS THE SIGN ”VOMITS EVERY THING” HAS THE CHILD HAD CONVULSIONS ? History of convulsion during current illness CLASSIFY THE ILLNESS AS ?

21. IDENTIFY THE TREATMENT Treat convulsions if present now by giving diazepam per-rectally. Complete assessment immediately. Give first dose of an appropriate antibiotic. Treat the child to prevent low blood sugar. Refer URGENTLY to hospital.

22. PRE-REFERRAL TREATMENT IMPORTANCE. CHARTBOOKLET: TREATMENT GIVEN IN CLINIC.

23. Practical session video demonstration

24. Facility based management Initially assess the child in triage. Look for emergency /priority signs. Give emergency treatment in the triage. Admit the child.

25. Facility Based Management The first step is, to assess referred case in the triage –where we screen the cases to decide to which of the following group(s) a sick child belongs: Those with emergency signs require immediate emergency treatment. Those with priority signs should alert you to for immediate assessment and treatment. Children with no emergency or priority signs are treated as non-urgent cases.

26. Emergency signs: Obstructed breathing Severe respiratory distress. Central cyanosis. Signs of shock Coma Convulsions Signs of severe dehydration

28. priority signs: Sick child < 2 months Temprature : child very hot Trauma or other urgent surgical Pallor Poisoning Pain Respiratory distress Lethargic/ irrtibility Severe malnutrition/visible wasting Edema on both feet. Burns.

31. Assessment of child with convulsion or coma AVPU scale. Alert Response to vocal commands. Response to pain Un-concouscious.

32. Stabilize and investigate CBC and MP CSF Blood glucose. Assessment of blood pressure Urine microscopy. Other investigations according to presentation ADMIT THE CHILD & MANAGE ACCORDINGLY

33. INPATIENT MANAGEMENT HISTORY FROM LOG BOOK FOR INPATIENTS DETAIL EXAMINATION & D/D FOLLOW INVESTIGATIONS NEED FOR FURTHER INVESTIGATION MANAGE ACCORDINGLY

34. Exercise question Salina is 15 months old weighs 8.5 kg with temp 38.5c. The mother said that Salina has been coughing for 4 days, and not eating well. This is her initial visit. Mother said that she does not want to breast feed. The health worker gave some water to Salin but she was too weak to lift her head. She was not able to drink. Mother said that she has no vomiting or convulsions. Salina was not lethargic or unconscious and not convulsing now.

35. Question Classify the illness. What information is missing What pre-referral treatment will you give to Salina

36. Key of exercise question Very sever febrile disease Malaria risk Anti biotics Antimalarial Sugar water Oral paracetamol.

37. Exercise question Kareena, a 4-year-old child has been urgently referred to you with classification of very severe febrile disease. Not very low weight and anaemia. She is from a high malaria risk area. She is in coma and has no signs of shock. The child is not severely malnourished and has some pallor. Her temperature is 39.2ºC.

38. Exercise question a) List the emergency signs. What emergency treatment would you give? b) Enlist important points in history and physical examination. c) What is your differential diagnosis? d) What investigations would you like to do?

39. key of Exercise question a. She has coma as emergency sign and high fever as priority sign. Manage airway, position, check and correct hypoglycaemia.

40. Key of Exercise question b. H/O skin rash, headache, ear pain. Look for stiff neck, skin rash, discharge from ear, splenomegaly. c. Meningitis, cerebral malaria, viral meningoencephalitis. d. LP, smear for MP and RDT, blood glucose, Hb and complete blood counts.