Acute Paediatrics. Not just ABC - MCHNV · A Cute Paediatrics . Objectives Paediatric clinical...
Transcript of Acute Paediatrics. Not just ABC - MCHNV · A Cute Paediatrics . Objectives Paediatric clinical...
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Acute Paediatrics.
Not just ABC
Dr David Krieser FRACP (PEM) Paediatric Emergency Physician
Sunshine Hospital
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A Cute Paediatrics
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Objectives
Paediatric clinical assessment The role of the Emergency Department
Work / Life balance
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The Universal (Paediatric)
History
• Maternal
• Pregnancy
• Labour and Delivery
• Perinatal
• Growth/Development
• Past Medical History
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Family History
Genogram
CF CF
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Examination
Playful but purposeful
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The 180 degree manoeuvre
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Investigation
Is it really needed?
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Investigation Readiness
Think about your approach
- Patient
- Family
- Staff (Call for help)
- Equipment
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Investigation Readiness
Don’t set up in front of the child
Don’t show needles
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The role of the ED
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Acute illness
management
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5 week old boy Background
• Maternal History
• Pregnancy
• Labour and Delivery
• Perinatal
• PHx
• Growth/Development
28 yr G2 P2 without significant PHx
Ultrasounds normal; GBS neg; Rubella
immune; Other serology negative; Diet
controlled GDM
Spontaneous onset at 37/40; NVD
Jaundice: phototherapy for 24 hours;
Urine/BM normal
No vaccines; normal baby check
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• Maternal History
• Pregnancy
• Labour and Delivery
• Perinatal
• PHx
• Growth/Development
28 yr G2 P2 without significant PHx
Ultrasounds normal; GBS neg; Rubella
immune; Other serology negative; Diet
controlled PIH
Spontaneous onset at 37/40; NVD
Jaundice: phototherapy for 24 hours;
Urine/BM normal
No vaccines; normal baby check
Breast feeding with formula top ups;
Gaining weight; No developmental
concerns
5 week old boy Background
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• Short history of rapid breathing
• minimal cough, minimal rhinorrhea
• no reported fever (tactile or measured)
• feeding reduced as he would pull away from the breast
and the bottle after a few sucks
5 week old boy Presentation
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• Vital signs
• Airway
• Breathing
• Circulation
• Disability (Neuro)
• Exposure
(Secondary survey)
Afebrile; HR 170; RR 40-60; Sats 97-100% in air
No stridor; breathing with pursed lips;
“puffing”; mild resp distress
CRT <2 sec; BP 66/44; pulses normal; no murmur
Quiet; Responds to Mum’s voice
Cutaneous
5 week old boy Examination
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Course
• Spiked fever
• completed septic screen
• IV flucloxacillin and cefotaxime
• bolus of saline
• ongoing respiratory issues
• Upper airway obstruction
• Nasopharyngeal airway - improved sleep; more settled but
frequent suction required
• NETS to NICU at RCH
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Course
• no surgical treatment required
• Cultures
• blood grew streptococcus
• CSF clear
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6 month old boy Background
• Maternal History
• Pregnancy
• Labour and Delivery
• Perinatal
• PHx
• Growth/Development
30 yr G4 P3; PHx Eczema
Ultrasounds normal; GBS neg; Rubella
immune; Other serology negative; Diet
controlled GDM
Spontaneous onset at term; LSCS for
fetal distress
Nil Significant
Vaccines up to date; No surgery; URTIs
Following centiles for length, weight and
HC. Rolls. Sits and slumps forward
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6 month old
Presentation
• 3 days rhinorrhea • 2 days cough, noisy breathing • 1 day reduced feeding and urine output • increased work of breathing
• “sucking in at the neck”
• “tummy moving while he’s breathing”
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• T 38.3 P 172 RR 50-70 Sats 88-92%
• No stridor, No tongue swelling
• Head bobbing; IC/SC recession; Abdominal wall
breathing; Inspiratory crackles; Expiratory wheeze
• Cool peripheries; normal pulses; CRT < 2 sec; Normal
HS
• Quiet, lethargic baby; eyes open; moving limbs
• Throat red; Conjuctival injection; Abdomen soft, liver
ptosed; No other mass; dry mucus membranes;
• Vital signs
• Airway
• Breathing
• Circulation
• Disability (Neuro)
• Exposure
(Secondary survey)
6 month old
Examination
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What is the diagnosis?
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Bronchiolitis
• Management Principles
A
B
C
D
E
OXYGEN
FLUIDS
FLUIDS
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Bronchiolitis
• Leading admission cause in infants Shay JAMA 1999 & Pelletier Pediatrics 2006
• Victoria 2006 - 2280 admissions • No clearly effective drug intervention, supportive care • Fluid replacement therapy required in 30% Johnson Pediatrics 2002
• Variable practice in Australia and NZ: PEM specialist survey 48% NGT; 52% IV
Babl PEC 2008
• No RCT evidence Smyth Lancet 2006
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The Comparative Rehydration in Bronchiolitis
(CRIB) study A/Prof Ed Oakley
for PREDICT
• Multicentre RCT in Australia and New Zealand (PREDICT Network)
• Winter 2009-2011
• Infants 2 to 12 months
• Clinical diagnosis of bronchiolitis and fluid replacement requirement
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Intervention
IV hydration - 0.45% saline with dextrose
OR
NG hydration - gastrolyte then normal feed
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Results
378
301 received allocated intervention
77 did not receive allocated intervention
381
357 received allocated intervention
24 did not receive allocated intervention
759 infants randomised
IV HYDRATION NG HYDRATION
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Results
• Demographics and baseline clinical characteristics were similar
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Results
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Results Number of insertion attempts for study-assigned method of rehydration
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CRIB study
Conclusions
• No difference in LOS between NG and IV hydration
• No difference in adverse events between NG and IV hydration
• More likely to insert NG tube on first attempt and, if not, to have fewer attempts at insertion
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Acute Injury
Management
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5 yo boy Fall on outstretched hand
(FOOSH)
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5 yr old boy Background
• Maternal History
• Pregnancy
• Labour and Delivery
• Perinatal
• PHx
• Growth/Development
• Family & Social History
Mo has lupus; currently stable
Aspirin; U/S;
Elective LSCS at 38+
Transient bradycardia – congenital heart
block.
Vaccines up to date; Tonsillectomy
Met milestones and followed age
appropriate percentiles
Parents separated; Occurred in Mum’s
care and presents with Dad.
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Adolescent Screening Not just for older children
H
E
A
D
S
Home
Education Employment
Activities
Depression Drugs (legal; illegal)
Suicidality Sexuality Spirituality
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5 year old boy
Presentation
• Fall from Skateboard
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• T 36.9 P 90 BP 140/65 RR 18 Sats 97%
• No stridor, No tongue swelling
• No respiratory distress; clear auscultation
• Cool peripheries; normal pulses; CRT < 2 sec; Normal
HS
• Quiet, Alert; GCS 15; moving limbs except L U/L
• Obvious deformity left forearm; ulnar and radial pulses
palpable; altered sensation in fingers (radial nerve
distribution
• Vital signs
• Airway
• Breathing
• Circulation
• Disability (Neuro)
• Exposure
(Secondary survey)
5 year old boy
Examination
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Limb Injury
• Management Principles
A
B
C
D
E Forearm deformity +++ Neurovascular assessment
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• Analgesia
• Non-Pharmacological
• splint
• explanation
• engagement without being contrived
• music
• Pharmacological
• oral
• intranasal
• inhaled
• intravenous
5 year old boy
Management
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• Fracture management
• Manipulation
• In Emergency
• In Theatre
• Immobilisation
• Follow up
5 year old boy
Management
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Uncertainty
Parental concern
GP concern
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“By the way,…”
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Presentations to ED
• Age distribution of emergency department presentations in Victoria Gary Freed et al EMA 2015; 27(2):102–7
• Paediatric ED referrals from primary care E Turbitt & G Freed Aust Health Rev. 2016 Mar 9. doi: 10.1071/AH15211
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What this is doing in the ED
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Education
• Preaching to the choir
• Advocacy
• Team approach
• Health care continuum
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Work / Life Balance
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Choose a job you love, and you will never
have to work a day in your life.
Confucious
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Another case
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74 year old female
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Family History
= medical practitioner
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WHAT WOULD YOU DO?
Call GP? Send for imaging?
Send to ED? Call a relevant colleague?
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WHAT DID I DO?
Send to ED? Call a relevant colleague?
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And then…
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pancreatic adenocarcinoma
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And then…
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“Life is what happens to us while we are making other plans” Alan Saunders Reader’s Digest 1957
John Lennon Beautiful Boy, Double Fantasy 1980
Issues - Distance
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Issues – Priorities
– family
– normalisation for children (one in year 12)
– work
– exercise
“Life is what happens to us while we are making other plans” Alan Saunders Reader’s Digest 1957
John Lennon Beautiful Boy, Double Fantasy 1980
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Issues – Fatigue
• Actual tiredness
• Emotional fatigue
• Uncertainty
“Life is what happens to us while we are making other plans” Alan Saunders Reader’s Digest 1957
John Lennon Beautiful Boy, Double Fantasy 1980
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Something like this will happen to all of us
• And it will usually be unexpected
• How do we manage this?
• Can we manage this?
• Strategies?
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Training
Knowledge
Skills
Attitudes
Nurse, Doctor…
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Skills Knowledge
Routines we know Reading Tutorials
Exams Work Based Assessments
Term Reports
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Are these important?
Why?
Can these be taught?
How do we teach these?
How do we assess these?
Attitudes
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Summary
• Develop a system to assist with diagnosis and management
• Communicate
• Ask questions
• including, “Are you ok?