Emergency Notes

Emergency

Acute Life Threatening Events (ALTE)

• Combination of apnoea, colour change, alteration in muscle tone, choking or gagging

• Most common in infants <10 weeks old

• May be the presentation of a patentially serious disorder although often no cause is identified

• Management required detailed history and thorough examination

• Infant should be admitted and mutiple overnight monitoring is indicated

• In most the episode is brief, with rapid recovery

• Causes

  • Infections RSV, pertussis

  • Seizures

  • Gastro-oesophageal reflux (present in 1/3 of normal infants)

  • Upper airway obstruction

  • No cause identified

• Uncommon causes

  • Cardiac arrhythmia

  • Breath-holding

  • Anaemia

  • Heavy wrapping / heat stress

  • Central hypoventilation syndrome

  • Cyanotic spells from intrapulmonary shunting

• Invesigations

  • Blood glucose (as soon as possible)

  • Blood gas (as soon as possible)

  • Oxygen saturation

  • Cardiorespiratory monitoring

  • EEG

  • Esophageal pH monitoring

  • Barium swallow

  • FBC, U&E, LFT

  • Lactate

  • Urine (collect and freeze first sample)

    • Metabolic studies

    • Microscopy and culture

    • Toxicology

  • ECG – for QT_c conduction pathway abnormality

  • CXR

  • Lumbar Puncture

Sudden Infant Death Syndrome

• Sudden and unexpected death of an infant or child for which no adequate cause is found after a through postmortem examination

• Occurs most commonly at 2-4 months of age

• Factors associated with SIDS

  • Infant

    • Age 1-6 months (peak is 12 weeks)

    • Low birthweight and preterm

    • Boys 60%

    • Multiple births

  • Parents

    • Low income

    • Poor/overcrowded housing

    • Maternal age <20 = 3x increased risk. However 80% of affected are 20+

    • Single unsupported mother

    • High maternal parity

    • Maternal smoking during pregnancy (>20 cigs increases risk x5)

  • Environment

    • Infant sleeps lying prone

    • Infant is overheated

• ‘Back to Sleep’ Campaign

  • Infants should be put to sleep on their back

  • Overheating should be avoided

  • ‘Feet to foot’ position

  • Parents should not smoke near their infants

  • Seek medical advice promptly if the infant becomes unwell

  • Baby in the bedroom for the first 6 months

  • Don’t take baby into bed when very tired or have taken alcohol/medication

  • Avoid sleeping with child on sofa or armchair

• Following the SIDS

  • Resuscitation

  • Care of parents specific staff member, history obtained

  • Baby pronounced dead Investigations include:

    • Nasopharyngeal aspirate

    • Blood for toxicology, metabolic screen, chromosomes if dysmorphic

    • Blood culture

    • Urine specimene – biochemistry, toxicology and freeze

    • Lumbar puncture – if indicated

  • Beaking the news to parents

    • Explain police will be involved but they are not being blames

    • Postmortem is required

  • Parents offered to see and hold baby

  • Initial strategy discussion

  • Home visit within 24 hours

    • Police visit

    • Paediatrician may attend

  • Postmortem

  • Case discussion at MDT

  • Follow up and bereavement counselling

Anaphylaxis

• Rapid onset and may be fatal

• Allergic immune responses may be IgE or non-IgE mediated

  • IgE mediated – previously sensitised B lymphocyte produced IgE Vs. antigen

  • IgE mediated reactions have a classical course

    • Early phase within minutes release of histamine and other mediators from mast cells urticaria, angioedema, sneezing, bronchospasm, shock

    • Late phase 4-6 hours later nasal congestion, cough and bronchospasm

• 85% in children is mediated by food allergy – most are IgE mediated reactions (as above)

• Other causes include insect stings, drugs, latex, exercise, inhalant allergens and idiopathic

• Acute management early administration of adrenaline

• Long term incolves allergence avoidance and management plans / provision of adrenaline

• Emergency Treatment

  • ABCDE

  • Diagnosis

    • Airway – swelling, hoarseness, stridor

    • Breathing – tachypnoea, wheeze, cyanosis, SpO₂ <92%

    • Circulation – pale, clammy, hypotension, drowsy, coma

  • Call for help / put patient in supine position with legs raised

  • Adrenaline 1:1000 IM

    • <6 years; 150 micrograms (0.15ml)

    • 6-12 years; 300 micrograms (0.3ml)

    • >12 years 500 micrograms (0.5ml)

  • If available

    • Establish airway

    • High flow oxygen

    • IV fluid

    • Chlorpheniramine

    • Hydrocortisone

  • Monitor

    • Pulse oximetry

    • ECG

    • Blood pressure

• Medium-long term management

  • Epipen IM adrenaline if needed for future use

  • Avoid causative allergen

  • Antihistamines if milder allergy

  • Steroids particularly important in preventing a late phase reaction

  • person can be desensitised to certain allergens using immunotherapy

• Investigations may include:

  • Serum histamine is elevated for around 30-60 minutes after reaction

  • Serum tryptase levels peak at 60-90 minutes

  • B-tryptase released with degranulation of mast cells Vs. tryptase secreted constitutively by mast cells

    • Ratio distinguishes systemic mastocytosis from anaphylaxis

  • Radioallergosorbent test/cutaneous antigen testing can be used after recovery - identify antigen

Poisoning

• May be:

  • Accidental – majority

  • Deliberate self poisoning in older childre

  • Non accidental (child abuse)

  • Iatrogenic

Accidental Poisoning

• Peak at 30 months

• 90% occur in the child’s own home when supervision is inadequate

• Clinical Features

  • Tachypnoea aspirin, carbon monoxide

  • Slow respiratory rate opiates, alcohol

  • Hypertension amphetamines, cocaine

  • Hypotension tricyclics, opiates, B blockers, iron

  • Convulsions tricyclics, organophosphates

  • Tachycardia cocaine, antidepressants, amphetamines

  • Bradycardia B blockers

  • Large pupils tricyclics, cocaine, cannabis, amphetamines

  • Small pupils opiates, organophosphates

• Toxicity

• Management

  • Identify agent

  • Assess toxicity

  • Is removal of toxin indicated (effective if <1 hour)

    • Activated charcoal (ineffective for iron, hydrocarbons and insecticides)

      • Do not use when risk of...

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