Sudden infant death and acute life-threatening events
Case 9: Case 9: A child with vomiting and altered conscious level
1 Yes. Altered conscious level is potentially life threatening as impaired consciousness means that the airway can be compro- mised. If a partially conscious patient vomits they may aspirate and risk respiratory arrest. Intervention to protect the airway includes positioning of the neck and chin and consider whether nasogastric tube should be placed to aspirate stomach contents.
Call anaesthetist as airway intubation may be needed.
2 Glasgow Coma Score (GCS) total 9:
• Eye opening 3 (to verbal command)
• Movement 4 (flexion with pain)
• Speech 2 (incomprehensible sounds)
3 He needs high-dependency one-to-one monitoring to observe for any further deterioration which would require urgent resuscita- tion. He should be moved to a resuscitation room or high- dependency unit. Continuous physiological monitoring of oxygen saturation, ECG, pulse rate, is necessary. High-frequency meas- urement of blood pressure, pupil responses, GCS, temperature and fluid balance is needed.
4 Diabetic ketoacidosis is suggested by the pattern of breathing, which indicates metabolic acidosis, and the history of nocturnal enuresis.
5 Blood glucose, gas, ketones will confirm diabetic ketoacidosis:
pH < 7.3, bicarbonate < 15, blood glucose > 11 mmol/L. Blood urea and electrolytes will help guide fluid management.
6
• Intensive monitoring during correction of metabolic and fluid derangement with aim to restore pH, glucose, potassium and fluid balance.
• Intravenous insulin is started 1 hour after intravenous fluids to stop ketogenesis and gradually correct blood glucose.
• Monitor particularly for cerebral oedema which can present with bradycardia or headache.
• If possible the process of investigation should be concluded quickly and alternative diagnoses excluded.
• The diagnosis should be communicated carefully so that child and family understand what is known about the condition and the uncertainty about the aetiology. It is helpful to explain that this is a pattern of illness that is not well understood but is seen repeat- edly in a large number of young people and adults.
• A combined approach of work with a team including paediatri- cian, physiotherapist and mental health staff is helpful to address the physical and psychological issues together. Gradual ‘pacing’
of activity and exercise to build up tolerance is recommended.
Psychological support to help understand any background prob- lems and cope with the social withdrawal and anxiety related to the illness is often helpful. Work with school to enable progressive staged re-inclusion alongside physical rehabilitation. In some situ- ations specialist pain team advice can be helpful.
• Drug-related—substance abuse, excessive anti-epileptic medication
• Endocrine—diabetes, Addison’s, hypothyroid
• Gastrointestinal—coeliac disease, inflammatory bowel disease
• Psychiatric—depression, eating disorder
2 Detailed history of the family and school background is impor- tant. Is there a history of illness affecting a close relative? What are the family and child’s beliefs about the illness mechanism and approach to management?
3 Full blood count and film, ESR, CRP, blood glucose, blood biochemistry, creatinine kinase, thyroid function, viral antibody titres to Epstein–Barr virus. Urine analysis for blood, protein, infection.
These are the initial screening investigations. Other investigations may be indicated if there are specific features in the history or examination.
4 The following steps are helpful in managing chronic fatigue:
Paediatrics at a Glance, Third Edition. Lawrence Miall, Mary Rudolf, Dominic Smith. © 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd. 157
Index
abdominal examination 14 abdominal pain 146, 152
acute 72–3 recurrent 80–1 abortion 141 abscess, ocult 62
abuse and neglect 91, 137–39 accident prevention 45 accidents 128 acid—base balance 25 acne 115
acute life-threatening events (infants) 142–3 acutely ill patients 118–20
cardiorespiratory failure 119–23 presentations 118
shock 119–20
unconscious child 124–5 adolescence 140–1 aggressive behaviours
pre-school 41, 43 school-aged 43 Agpar score 30
normal 31 AIDS 63 airways
examination 12–13 resuscitation 30–1, 121–3 alcohol abuse 141 alcohol poisoning 129 allergies 116–17 anaemia 24, 104–5 anaphylaxis 116–17 anencephaly 33 angioedema 117 anorexia nervosa 141 antibodies 28 aortic stenosis 58–9 aortic valve stenosis 56 appendicitis 72–3
arthritis, juvenile idiopathic 100, 101 asphyxia 31
asthma 64–5, 67–69, 116–17 atopic dermatitis 115 atrial septal defect 56, 58–9 atrioventricular septal defect 56
attention deficit hyperactivity disorder (ADHD) 43
auscultation 12, 13 autism 134–135 autonomy 145
autosomal dominant polycystic kidney disease (ADPKD) 85
autosomal recessive polycystic kidney disease (ARPKD) 85
Barlow test 33, 33 basic life support 122–3
BCG (bacille Calmette-Guérin) immunizations 46–7
bedwetting 88
behaviour problems 40–1 biliary atresia 106–7 biliary stones 73
birth 30–1 birthmarks 111 bladder anomalies 84–5 blood constituents 24 blood culture 28 blood film 24 blood gases 25 blood pressure 13 body tone 15 bone marrow failure 104 suppression 109 bowel habit 14 bowel obstruction 74–5 bowlegs 103
brain
imaging 27–8
intracranial pressure 74–5, 92–3 tumours 93, 108
brain injury, preterm infants 37–37 breast-feeding 30, 38–9
breast-milk jaundice 106–7 breath sounds 12 breath-holding 94–5 breathlessness 12, 13 Bristol stool chart 82 bronchiolitis 64–5 bullimia 141 bullying 43 burns 128
C-reactive protein (CRP) 28 café au lait spots 111 calcium, homeostasis 25 cancer 108–9
Candida infections, skin rashes 112 capillary refill time (CRT) 13 cardiac arrest 118–19, 121–3 cardiac arrhythmias 94–5 cardiac massage 122–3 cardiorespiratory arrest 121–3 cardiovascular system 13 cataracts 16
cerebral palsy 98–9 cervical adenitis 67 chest radiography 26–7 chest wall
anomalies 103 cardiac massage 122–3 examination 12 chicken pox 113 child abuse 91, 137–9 child care 42
child development see development Children’s Centres 42
choking 122, 128 chromosomal disorders 35 chronic illness 130–1 circulation 13 circulatory failure 119 cleft lip and palate 32, 33
clinical presentations, observations 11 clotting mechanisms 24
coarctation of aorta 56, 58 coeliac disease 48, 78–9
growth patterns 22 cold sores 114 colic 41, 73
collapsed child 121–5, 149, 153–4 coma 125–6
communication skills, consultations 10 complement 29
confidentiality issues 144 congenital abnormalities 32–4 congenital heart disease 56–7
congenital hip dysplasia (CDH) 17, 33, 103
conjunctivitis, allergic 116–17 consciousness 15, 153, 155 consent issues 144
constipation 72, 79, 82–3, 148, 153 consultations 10–11
convulsions 94–5, 120 Coombs test 24 coordination 15 cot deaths 142–3 cough 13, 64–5, 148, 153 cover test 16
cradle cap 112 cranial nerves 15 craniosynostosis 103
critically ill children see acutely ill patients Crohn’s disease 78–9, 100
croup 64–5, 66 crying 40–1 CSF analysis 28–9 CT scans 27–8 Cushing’s disease 50–1 cyanosis 13, 56–7, 94–5, 148, 154
cystic fibrosis (CF) 35, 48, 70–1, 78–9, 149, 155
cytomegalovirus (CMV) 91 dehydration 76–7
depigmentation patches 111 dermatitis
atopic 115 contact 115–16 groin area 112 seborrhoeic 112, 115 development
fine motor 19 gross motor 18 history taking 11 key milestones 20 social 19
speech and language 19 warning signs 20
developmental delay 90–1, 145, 150 developmental dysplasia of the hip (DDH)
33
diabetes mellitus 53–55 diabetic ketoacidosis 25, 53–4, 73 diarrhoea
acute 76–7 chronic 78–9
diphtheria 46–7 disability 132–3
doctor—patient relationship communication skills 10 consultations 10–11 Down’s syndrome 33, 91, 135
screening 35 drowning 128 drowsiness 120 drug abuse 141 drug overdose 129 dying child 144 dyslexia 43 dyspraxia 43 ear disorders
clinical examination 12 infections 60–1
see also hearing impairment ear, nose and throat examination 12 eating problems
adolescents 141 young children 40 ectopic testes 89 eczema 115–7
education, legal requirements 42 Edward’s syndrome 33 electrolytes 25, 77–77
emergency medicine see acutely ill patients emotional abuse 138
encephalitis 125 encopresis 83 end-of-life care 144 endocarditis 59, 62–3 enuresis 88 epiglottitis 65, 66 epilepsy 94–5, 96–7
ESR (erythrocyte sedimentation rate) 24, 28 ethical considerations 144
eyes, clinical examination 16 facial features, dysmorphic 32 faecal impaction 83
failure to thrive 48–9, 91, 138, 146, 151 fainting 13, 94–5, 148, 153–4 falls 128
febrile convulsions 127 feeding problems 40–1, 74 femoral epiphysis 102 fetal alcohol syndrome 91 fever 148, 153
acute 60–1 persistent 62–3 unknown origins 63 Fifth disease 113 fine motor development 19 finger clubbing 13, 70 fits 94–5, 127, 148, 153–4
see also epilepsy flat feet 103 fluid balance
dehydration 76–7 requirements 77 food intolerances 116–17 foreign bodies, inhaled 64, 66 Fragile X syndrome 135 fundoscopy 16
gait analysis 17 limp 102 gastritis 80–1
gastro-oesophageal reflux 48, 74–5 gastroenteritis 74–5, 76–7 gastrointestinal conditions
abdominal examination 14 acute abdominal pain 72–3 electrolyte disturbances 25 vomiting 74–5
genetic disorders 35 genetic inheritance 35 genetic testing 34–5 genitalia 14
development 23 genito-urinary symptoms 14 genu varum/valgum 103 germ cell tumours 108 gestation periods 30
Giardia lamblia infections 78–9, 80–1 glandular fever 61, 62
glass test 120
Goldenhar syndrome 33 grasp 19
groin swellings 89, 148–9, 154 gross motor development 18 growing pains 102 growth, patterns 21–2, 50–1 growth hormone deficiency 22, 50–1 habits 40–1
haematology 24 haematoma 27 haematuria 86–7 haemoglobin 24
haemolytic disease of the newborn 107 haemolytic uraemic syndrome (HUS) 87 haemophilia 100
hay fever 116–17 head circumference 21 head lice 114
headaches 92–3, 120, 145–6, 151 health promotion and education 42, 44–5 health visitors 44
hearing impairment 136 heart disease 56–7 heart failure 13, 56
heart murmurs 13, 56, 58–9, 146, 152 height measurement 21–2
Heimlich manoeuvre 122
Henoch-Schonlein purpura 72, 100, 115 hepatitis 47, 62, 106
immunization 46 hepatomegaly 13
hereditary conditions see genetic disorders hernia, inguinal 89
herpes simplex virus 114 Hib immunization 46–7 hip disorders 17, 103 hip dysplasia 17, 33, 103 Hirschprung’s disease 83 history taking see medical history HIV infection 62–3
HPV (human papillomavirus) 47 human rights 144
hydrocele 89
hydrocephalus 22 hyperbilirubinaemia 106–7 hyperkalaemia 25 hypernatraemia 25, 77 hyperventilation 94–5 hypoglycaemia 54, 94–5 hypokalaemia 25 hyponatraemia 77 hyposplenism 63 hypothyroidism 50–1
congenital 35, 91 immunizations 45, 46–7 immunodeficiency 63
immunological investigations 29 immunosuppression 109 impetigo 114
inborn errors of metabolism 91 infection
fevers 60–1 investigations 28–9
infectious mononucleosis 61, 62, 67 infective endocarditis 59, 62–3 inflammatory bowel disease 62, 72, 78–9 inguinal hernia 89
inguinal lymphadenopathy 89 inhaler devices 69
insulin therapy 55
intensive care withdrawal 144 intestinal obstruction 72
intrauterine growth retardation (IUGR) 22, 31, 48
intrauterine infections 91 intussusception 72–3 investigations 28–9 iron deficiency anaemia 105 irritable bowel syndrome 80–1 jaundice 106–7, 148, 154 joints
examination 17 swollen 100, 146, 151
juvenile idiopathic arthritis 100, 101 Kawasaki’s disease 60, 115 Kayser-Fleischer rings 107 kernicterus 107
kidney abnormalities 84–5 knock-knees 103 Koebner phenomenon 117 laboratory investigations 28–9 lactation 38
lactose intolerance 78–9 language development 19 laryngeal abnormalities 66 laryngomalacia 66 laxatives 83 lead poisoning 104
learning disability 37, 43, 90–1, 135 leg anomalies 103
leg pain 102
Legg-Perthes disease 102 leucocytosis 24, 28 leukaemia 24, 104, 108–9 limp 102
long-term conditions 130–1
Index 159 lumbar punctures 28–9
lung collapse 28 lymph glands 67
nodules 89 lymphoma 67, 108 macules 110 maculopapular 110 malabsorption 49, 78 mastoiditis 67 maturational delay 51
MCH (mean cell haemoglobin) 24 MCV (mean cell volume) 24 measles 47, 113
meconium 30 meconium ileus 71
medical care, school-based 44–5 medical ethics 144
medical history 11
cardiovascular problems 13 gastrointestinal conditions 14 neurological conditions 15 nutritional status 14 respiratory conditions 12–13 vision and eye conditions 16
medium-chain acylcarnitine deficiency (MCAD) 35
mellaria 112
meningitis 47, 119–20, 126 skin presentations 113, 120 meningocele 33
meningococcal septicaemia 113, 119–20 menstruation 142
mesenteric adenitis 72–3 metabolic acidosis 25, 77 metabolic alkalosis 25, 77 migraine 92–3
milia 112
milk protein intolerance 78–9 MMR vaccine 46–7
mobility, gross motor development 18 molluscum contagiosum 114 Mongolian blue spot lesions 111 mortality rates
infants 30 perinatal 30 MRI scans 27
multicystic dysplastic kidney 85 mumps 47, 67
musculoskeletal examination 17
musculoskeletal problems, common presentations 103
mycobacterium infections 67 myelomeningocele 33 nappy rash 112 neck stiffness 120 neck swellings 67 necrotizing enterocolitis 37 neglect 91, 137–8 neoplastic disease 102 nephroblastoma 108 nephrotic syndrome 86–7, 118 neural tube defects 33–4 neuroblastoma 108
neurocutaneous syndromes 91 neurofibromatosis 91
neurological examination 15 infants 16
neuropathic bladder 84 neutropenia 24 newborn infants 30–1
examination 32 night terrors 41 nightmares 41
non-accidental injuries 137–9 Noonan’s syndrome 33 nutrition 38–9
education 45 infants 38–9 pre-school years 39 school-age children 39 status 14
obesity 52–3, 146, 152 observation of the child 11
respiratory system 12 ocular movements 16 online resources 151 optic glioma 27 Ortolani test 33 osteomyelitis 62–3, 102 otitis media 60–1 ovarian cysts 73 paediatric care
disability provisions 134 long-term conditions 132 paediatricians 44
pallor 104–5 palpation 12, 13, 14 palpitations 94–5 papules 110
paracetamol overdose 129 parasites 78–9, 80–1 parental support 45 parotid glands 67 Patau syndrome 33 patent ductus arteriosus 56–7 peptic ulcers 72, 80–1 percussion 12, 14 Perthes disease 103 pes planus 103
phenylketonuria (PKU) 35, 91 phimosis 85
pigmentation disorders 111 plagiocephaly 103 platelets 24
pneumococcal infections 46–7 pneumonia 64–5
radiography 26 referred pain 73 poisoning 129 polio 46–7 potassium 25, 77–77 pregnancy, teenage 141 premature infants
assessment and examination 36 complications 36–7
definitions 37 growth 22 survival rates 36 proteinuria 86–7 psoriasis 100, 112, 115
puberty 23
pulmonary stenosis 58–9 pulmonary valve stenosis 56 pulse 13
purpura 110
pyloric stenosis 25, 74–5 quality of life considerations 144 raised intracranial pressure 74–5, 92–3 range of movement (ROM) assessments 17 rashes 110
infections and infestations 113–14, 120 inflammatory disorders 115
newborn and infants 111–12 non-blanching 120 rectal examination 14 red flags 118 red reflex 16
reflex anoxic seizures 94–5 reflexes 15
renal anomalies, congenital 84–5 renal calculi 72–3
renal failure 86–7 renal tumour 86 respiratory acidosis 25 respiratory alkalosis 25 respiratory depression 118 respiratory distress syndrome 37 respiratory failure 120–1 respiratory rates 12 respiratory system 12
respiratory tract infections 60–1 respiratory tract obstructions 119–20 resuscitation 121, 123
newborn infants 30–1 retinoblastoma 16, 108
retinopathy of prematurity (ROP) 37 Reye’s syndrome 107, 125
rhabdomyosarcoma 108 rhesus incompatibility 106 rhinitis 116–17
rickets 103 ringworm 114
road traffic accidents 128 rubella 46–7, 91, 113 safeguarding children 45, 139 scabies 114
scalded skin syndrome 113 school
chronically ill children 131 common difficulties 43 special needs provisions 133 transitions 133
school nurses 44 scoliosis 17, 103 screening 34–5 scrotal swellings 89 seborrhoeic rashes 112, 115 seizures 96–7
self-harming 141 sepsis 75, 119
septic arthritis 60, 100, 102 septic shock 119–20
septicaemia, meningococcal 113 serological activity 28