Aims & objectives Organ Emergency Respiratory Croup - - PowerPoint PPT Presentation

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Aims & objectives Organ Emergency Respiratory Croup - - PowerPoint PPT Presentation

Aug 11, 2023 178 likes •598 views

Aims & objectives Organ Emergency Respiratory Croup Bronchiolitis Viral induced wheeze Asthma exacerbation Epiglottitis Neurology Seizures Pyloric stenosis Gastroenterology and Intussusception surgery ALL Haematology Sickle cell

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Aims & objectives

Organ Emergency

Respiratory Croup Bronchiolitis Viral induced wheeze Asthma exacerbation Epiglottitis Neurology Seizures Gastroenterology and surgery Pyloric stenosis Intussusception Haematology ALL Sickle cell crisis Infection Meningitis Sepsis Other Anaphylaxis Kawasaki disease

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Case-based discussion: 1

History

A 7-year-old child is rushed into the emergency department by his mother. He is breathing heavily and struggling to complete sentences in

  • ne
  • breath. He appears drowsy and confused. The

patient has a history of asthma. On examination, you note intercostal recessions and a generalized wheeze. His PEFR is 39% of his baseline.

Observations

HR 126, RR 35, SpO2 89%, Temp 38.1 (HR: 70-110) (RR: 20-25)

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Question: 1

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Case-based discussion: 1

History

A 7-year-old child is rushed into the emergency department by his mother. He is breathing heavily and struggling to complete sentences in

  • ne
  • breath. He appears drowsy and confused. The

patient has a history of asthma. On examination, you note intercostal recessions and a generalized wheeze. His PEFR is 39% of his baseline.

Observations

HR 126, RR 35, SpO2 89%, Temp 38.1 (HR: 70-110) (RR: 20-25)

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Definition: airway bronchospasm and inflammation resulting in airway obstruction Epidemiology

  • Asthma affects 11.6% children aged 6-7 (NICE)
  • 60,000 hospital admissions per year in the UK

Risk factors

  • Viral infection
  • Inhaled allergens
  • Exercise
  • Emotion
  • NSAIDs

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Introduction: Asthma Exacerbation

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Pathophysiology: Asthma Exacerbation

Inflammatory response is driven by T-helper type 2 (Th2-cells)

  • 1. Bronchial inflammation and bronchospasm
  • Terminal bronchioles
  • 2. Bronchial obstruction
  • Increased mucous production and mucosal
  • edema
  • Bronchospasm
  • Smooth muscle hypertrophy
  • 3. Bronchial hyperresponsiveness
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Clinical features

Symptoms Signs

Evidence of trigger Respiratory distress Breathlessness Wheeze Reduced feeding Exhaustion Reduced GCS

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Moderate Severe Life-threatening

SpO2 ≥ 92% SpO2 < 92% SpO2 < 92% and any of: No features of severe asthma Too breathless to talk or feed PEFR < 33% (aged >5) Aged 2-5

  • HR > 140
  • RR > 40

Silent chest Aged > 5

  • HR > 125
  • RR > 30
  • PEFR 33-50%

Poor respiratory effort Use of accessory neck muscles Agitation Exhaustion Hypotension Cyanosis Confusion

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Investigations: Asthma Exacerbation

Bedside

  • PEFR
  • Moderate: > 50%
  • Severe: 33-50%
  • Life-threatening: < 33%

Bloods

  • Blood gas: evidence of respiratory failure (type 1
  • r type 2)
  • Inflammatory markers: raised if there is an

infective trigger

Imaging

  • CXR: hyperexpansion and/or evidence of infection

(1)

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Question: 2

History

A 7-year-old child is rushed into the emergency department by his mother. He is breathing heavily and struggling to complete sentences in

  • ne
  • breath. The patient has a history of asthma.

On examination, you note intercostal recessions and a generalized wheeze. His PEFR is 39% of his baseline.

Observations

HR 126, RR 40, SpO2 89%, Temp 38.1 (HR: 70-110) (RR: 18-30)

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Question: 3

History

A 7-year-old child is rushed into the emergency department by his mother. He is breathing heavily and struggling to complete sentences in

  • ne
  • breath. The patient has a history of asthma.

On examination, you note intercostal recessions and a generalized wheeze. His PEFR is 39% of his baseline.

Observations

HR 126, RR 40, SpO2 89%, Temp 38.1 (HR: 70-110) (RR: 18-30)

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Management: Asthma Exacerbation

Oxygen: aim for SpO2 ≥ 94% Bronchodilators: inhaled or nebulised if hypoxic

  • Salbutamol +/- Ipratropium
  • BURST/back to back: 3 salbutamol nebulisers

and 1 ipratropium nebulsier Corticosteroid

  • Prednisolone PO
  • Hydrocortisone IV if unable to tolerate

IV bronchodilation

  • MgSO4, Salbutamol, Aminophylline

Intubation and ventilation

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Differential diagnosis: Respiratory distress

Bronchiolitis Croup Viral induced wheeze Asthma exacerbation Pneumonia

< 1 year < 3 years < 5 years > 5 years Any age

  • 9 day illness
  • RSV
  • Barking cough
  • Parainfluenza

virus

  • Wheeze
  • Generally well

in between episodes

  • Wheeze
  • Symptomatic

between episodes

  • Productive

cough

  • High fever
  • Crepitations

If the child requires admission:

  • Bloods including capillary blood gas
  • CXR
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Case-based discussion: 2

History

A 6-week-old male presents with multiple episodes

  • f projectile vomiting after feeding. You note a

visible olive shaped mass in the abdomen. He has had 2 wet nappies in the last 24 hours. When observing him being fed in the emergency department, he vomits 10 minutes later. He has mottled skin and a capillary refill time of 3 seconds.

Observations

HR 170, RR 55, SpO2 95%, Temp 37.2 (HR 110-160) (RR 30-60)

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Question: 4

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Case-based discussion: 2

History

A 6-week-old male presents with multiple episodes

  • f projectile vomiting after feeding. You note a

visible olive shaped mass in the abdomen. He has had 2 wet nappies in the last 24 hours. When observing him being fed in the emergency department, he vomits 10 minutes later. He has mottled skin and a capillary refill time of 3 seconds.

Observations

HR 170, RR 55, SpO2 95%, Temp 37.2 (HR 110-160) (RR 30-60)

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Definition: hypertrophy of the pyloric smooth muscle

  • f the stomach

Epidemiology

  • 2-4 per 1000 live births
  • More common in males

Risk factors

  • Age: 2-6 weeks of age
  • Male: 4x more common
  • First born
  • Family history
  • Caucasian
  • (Maternal macrolides)

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Introduction: Pyloric Stenosis

(2)

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HCl K+ Na+

(3)

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Metabolic alkalosis

  • Loss of gastric acid (HCl)

Hypochloraemia

  • Loss of chloride ions (HCl)

Hypokalaemia

  • Loss of potassium ions
  • Hypovolaemia

activates the renin-angiotensin-aldosterone system à sodium reabsorption and potassium excretion

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Introduction: Pyloric Stenosis

(2)

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Clinical features

Symptoms Signs

Projectile non-bilious vomiting post- feed Evidence of dehydration

  • Capillary refill time > 2s
  • Mottled skin
  • Dry mucous membranes
  • Sunken fontanelle

Reduced wet and dirty nappies Visible peristalsis Poor weight gain Olive shaped mass in the upper abdomen

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Clinical features

(4)

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Investigations: Pyloric stenosis

Bedside

  • Test feed: observe for vomit
  • Glucose

Bloods

  • Capillary blood gas: pH, Na, K, Cl, HCO3, lactate
  • Hypochloraemic, hypokalaemic, metabolic alkalosis
  • Urea & electrolytes

Imaging

  • Abdominal USS: sensitivity 99%
  • >3mm thickness of the pyloric muscle

(5)

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Management: Pyloric stenosis

Management

  • Supportive
  • NBM and NG tube decompression:

stomach decompression

  • IV

fluids: rehydration and replacement of electrolytes

  • Surgical
  • Ramstedt pyloromyotomy: incision
  • f the muscles of the pylorus

(6)

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History

A 7-month-old child presents to the emergency department with his mother. The child is lethargic and floppy. He is visibly very pale and has a distended abdomen. The mother reports the child has been vomiting and has passed red coloured stool on a few occasions. You note him drawing up his legs to his abdomen and start crying.

Observations

HR 190, RR 66, SpO2 94%, Temp 37.5 (HR 110-160) (RR 30-60)

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Case-based discussion: 3

(7)

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Question: 5

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History

A 7-month-old child presents to the emergency department with his mother. The child is lethargic and floppy. He is visibly very pale and has a distended abdomen. The mother reports the child has been vomiting and has passed red coloured stool on a few occasions. You note him drawing up his legs to his abdomen and start crying.

Observations

HR 190, RR 66, SpO2 94%, Temp 37.5 (HR 110-160) (RR 30-60)

28

Case-based discussion: 3

(7)

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Definition: telescoping of a proximal segment of bowel into a distal segment Epidemiology

  • Rare: 30-100,000 infants
  • Most common in males

Aetiology

  • Lead-point hypothesis

Risk factors

  • Age: 6-18 months
  • Viral infection
  • Henoch-Schonlein purpura
  • Lymphoma

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Introduction: Intussusception

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Pathophysiology: Intussusception

  • Viral infection: hyperplasia of Peyer’s patches
  • Henoch-Schonlein purpura: submucosal

haematoma

  • Lymphoma

(8)

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Clinical features

Symptoms Signs

Colicky abdominal pain

  • Episodic crying and agitation
  • Drawing knees up to the chest

Abdominal mass Bilious vomit Abdominal distention Bloodstained stool: ‘redcurrant’ jelly Hypotension and tachycardia

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Clinical features

(7)

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Question: 6

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Investigations: Intussusception

Bedside

  • Glucose

Bloods

  • Capillary

blood gas: raised lactate with metabolic acidosis if bowel ischaemia

  • FBC: anaemia
  • Urea and electrolytes: dehydration and AKI

Imaging

  • Abdominal USS: diagnostic investigation
  • Contrast enema: diagnostic and therapeutic

(9)

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Management: Intussusception

First line:

  • Resuscitation: ABCDE
  • IV fluids and blood products may be needed
  • IV antibiotics: prevent abdominal sepsis
  • Radiological reduction: air or contrast

Second-line:

  • Surgery: resection may be needed
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Differential diagnoses: Vomiting

Bilious (green) Non-bilious

Intestinal obstruction

  • Volvulus
  • Intussusception
  • Hirschsprung's disease

Gastroesophageal reflux Gastroenteritis Gastroenteritis Necrotising enterocolitis Pyloric stenosis

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Top-decile question

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Top-decile question

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Recap

  • The severity of an asthma exacerbation is dependent on the SpO2, PEFR, and clinical

presentation

  • Management of acute asthma is with oxygen, bronchodilators, and corticosteroids
  • Pyloric stenosis presents in young infants around 6 weeks of age
  • Non-bilious projectile vomiting post feeding is typical
  • Management is surgical
  • Intussusception is usually seen around 6 months of age
  • In exams it will often be associated with red-currant stool
  • Management is with air or contrast enema reduction
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References

1. Mikael Häggström.When using this image in external works, it may be cited as:Häggström, Mikael (2014). &quot;Medical gallery of Mikael Häggström 2014&quot;. WikiJournal of Medicine 1 (2). DOI:10.15347/wjm/2014.008. ISSN 2002-4436. Public Domain.orBy Mikael Häggström, used with permission. / Public domain 2. Henry Vandyke Carter / Public domain 3. This SVG image was created by Medium69.Cette image SVG a été créée par Medium69.Please credit this : William Crochot / Public domain 4. Xxjamesxx / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 5. Dr Laughlin Dawes, wikicommons 6. Schuetdm / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 7. Amanda Slater from Coventry, West Midlands, UK / CC BY-SA (https://creativecommons.org/licenses/by-sa/2.0) 8. Olek Remesz (wiki-pl: Orem, commons: Orem) / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0) 9. James Heilman, MD / CC BY-SA (https://creativecommons.org/licenses/by-sa/3.0)

All other images were made by BiteMedicine or under the basic license from Shutterstock and not suitable for redistribution

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