Gastrostomy - Common problems

Tube Issues

Blocked tube

Causes:

Poorly crushed medications Not flushing gastrostomy tube when feeds are completed Feed too thick or containing lumps of powder Vitamised food being put down tube Leaving formula in the tube to curdle

To unblock the gastrostomy tube, flush it with 10 - 20 ml of a carbonated drink such as mineral water or diet cola. Sometimes the blockage can be aspirated out using a syringe.

Peri-stomal Issues

Leakage around the tube

Related to the relative sizes of the tube and stomal tract. If the tube is too small for the opening, it may need replacement with a larger tube.

Other possible causes include:

1. Deflated or ruptured balloon. This can be checked by attempting to drain the balloon. If there is no fluid the balloon may be deflated or have burst. Injecting water into the balloon and then checking if the volume is the same when draining will indicate if there has been a rupture. If the balloon has burst the tube will need replacing. The only sure way to tell is to remove the tube.

2. Tube deterioration or damage Tube may need replacement.

3. Tube Migration The tube may have migrated down the stomach and the balloon is not flush with the gastric mucosa. Putting gentle traction on the tube and then adjusting the retention disc to fit snugly against the abdominal wall may help.

Skin excoriation

Gastric secretions leaking around the gastrostomy can result in skin excoriation. There are two methods of minimising irritation to the skin:

1. Use of a barrier ointment (better than cream) o Recommended products include Calmoseptine™ ointment, Ilex™ barrier ointment, or

a zinc ointment. o If the site is affected by thrush, do NOT use a zinc based product as this may worsen

the infection. Suitable alternatives include Orabase™ or Coloplast™ paste. 2. Medications to halt gastric acid production.

o Ranitidine and/or Omeprazole.

Red, irritated, swollen, oozing skin surrounding a gastrostomy can be treated with:

A foam dressing, gauze or Sofwick to absorb excess ooze Topical Magnesium + aluminium hydroxide preparations (eg Mylanta)

Hydrocolloid powder to aid in stopping bleeding and absorb excess moisture A thin hydrocolloid dressing (eg Duoderm wafer) to protect and aid in healing of excoriated

skin

Granulation tissue

Granulation tissue usually occurs about 6 weeks post surgery. It may be caused by the tube moving too freely. If this is the case an anchor device eg FlexiTrak can be useful.

Options to treat granulation tissue:

A foam dressing to apply pressure to reduce granulation. Silver nitrate application daily (to granulation tissue only) Application of a steroid cream

Infections

Candida; under the skin flange, use topical antifungal preparations eg clotrimazole or nystatin.

Cellulitis (see photo); is normally due to staphylococcal infection (but can involve enteric flora) and appropriate antibiotics should be given eg oral or intravenous flucloxacillin. If the site is very swollen, the tube may have to be removed to relieve pain. If there is discharge from the site, a skin/wound swab should be sent for microscopy and culture prior to commencing treatment.

These should only be prescribed by the treating unit. Haematuria

Haematuria is the presence of red blood cells in the urine. The presence of 10 or more RBCs per high-power field is abnormal.

Urinary dipsticks are very sensitive and can be positive at <5 RBCs per high-power field.

Red or brown urine does not always indicate haematuria (haemoglobinuria, myoglobinuria, medication, and food).

Urate crystals are commonly present in the urine of newborn babies. They can produce a red discolouration of the nappy ("brick dust" appearance) which is sometimes mistaken for blood.

Blood in the urine may come from sources other than the urinary tract (eg vaginal haemorrhage, rectal fissure).

Common causes for microhaematuria include in association with viral infections, UTI, Trauma, HSP.

If you find microscopic haematuria in the setting of an acute febrile illness, exclude UTI by urine culture and arrange for the urine to be tested again after the acute illness has passed.

Common causes for macroscopic haematuria include the above. It is more likely to come from the bladder or urethra.

Symptomless or "Benign Haematuria" in children without growth failure, hypertension, oedema, proteinuria, urinary casts or renal impairment is a frequent finding.

In the emergency department it is important in evaluating a child with haematuria to identify serious, treatable and progressive conditions.

Many children with isolated microscopic haematuria require no immediate investigation and simply need to be checked to see if the problem persists. This should be arranged with the general practitioner or through outpatient clinic if the family do not have a GP.

Larger view of flowchart Headache

Introduction

Headache is a common symptom in children, affecting 80-90% by age 15. The common causes are systemic illness with fever, local ENT problems, migraine and tension headache. Meningitis, raised intracranial pressure (ICP) from tumours etc. and subarachnoid haemorrhage (SAH) are much rarer causes but these need to be considered.

Assessment

History

It is useful to classify headache as acute or recurrent. The following list gives the causes and key features to help make a diagnosis, based on careful history and examination:

Acute

Systemic with fever general illness (e g flu, pneumonia, septicaemia) Local sinusitis, dental caries, otitis media Trauma head injury Meningitis reduced conscious level, toxicity, photophobia, neck stiffness SAH sudden onset, severe occipital pain; possible reduced conscious level, neck stiffness

Recurrent

Migraine: aura, nausea, vomiting, pallor, family history Tension: throbbing pain (involving neck muscles) at end of day Behavioral: family/social/school problems (may be difficult to identify) Raised ICP: morning headaches +/- vomiting, worse on or coughing/sneezing/bending,

progressively worsening, personality or behavioral changes, focal neurological symptoms

(Others - Benign intracranial hypertension, systemic hypertension, uremia, recurrent hypoglycemia, recurrent seizures, lead or CO poisoning)

See Headache Patterns (it may be helpful to show the child / family this chart and to ask them to identify the pattern themselves)

Examination

As part of the examination it is important to document the following:

ABC: blood pressure, heart rate General: toxic, unwell, temperature, rash. Neurology: conscious level, fundi, visual fields, cerebellar signs, neurocutaneous stigmata,

neck stiffness, cranial bruits. Local causes: cervical lymphadenopathy, teeth, sinus, ears. Growth and puberty: head growth, height, weight, growth velocity, pubertal status.

Investigations

In the acute situation, the two most important questions to answer are:

Does the child need a CT scan of the head? Should a lumbar puncture (LP) be performed?

1. If the child has altered state of consciousness, focal neurological signs, raised blood pressure, or papilloedema, there is a need for urgent assessment with consideration of CT scan of head +/- acute management of raised ICP. (discuss with consultant).

2. Consider LP (in the absence of the contraindications) if concerned about meningitis or SAH. May need CT scan first (discuss with consultant).

3. If there are no symptoms and signs suggesting raised ICP/SAH/meningitis and the story is suggestive of migraine then treat symptomatically (see below).

4. If other causes apparent consider appropriate investigations. (eg. septic screen, urea, carboxyhaemoglobin or lead level [wrist X-rays], blood sugar profile).

Management

If there is a specific diagnosis such as meningitis, SAH, tumour, systemic infection or local infection, then treat as appropriate. Most recurrent headaches can be managed by a paediatrician and do not need to be referred to a neurologist.

Migraine:

Abort attack

Avoid opiates Initially simple oral analgesics such as paracetamol (20mg/kg stat then 15 mg/kg/dose 4H

(max 4g/day) or codeine (1 mg/kg/dose 4 hrly) or NSAID(ibuprofen 2.5-10mg/kg/dose 6-8 hrly)

Adolescents - 1g of aspirin, 1g of paracetamol, 10 mg of metoclopramide. * If vomiting is a prominent feature in children over 10 years slow IV prochlorperazine (0.1-

0.2mg/kg).

In older children consider slow IV chlorpromazine (0.25-1mg/kg/dose: max 50mg).

Prophylaxis

(Refer to General Paediatric Outpatient Clinic for long term management)

Consider beta blockers, pizotifen, calcium channel blockers Non-pharmacological interventions (eg. avoidance of triggers, relaxation) often play an

important role in prevention. Parent Information Sheet on Migraine Headache (Print version - PDF)

Migraine headache

Migraine is a disorder that causes repeated headache. Some children get only occasional attacks, while others get them more than once a week. The headaches can range from being mild to very severe. Migraines happen when blood vessels of the head and neck spasm or become narrow (constrict). Minutes to hours later, the blood vessels enlarge (dilate). When they dilate, they fill with blood which causes more pressure in the skull, and so, a headache.

Migraine headaches happens in about 6 out of 100 people. They are common in children. In many cases they appear to run in the family. Migraine is not a serious or life-threatening disorder. It is painful and annoying at the time, but it is not usually a serious problem. About half of children who get migraines will continue to have them when they are adults.

Signs and symptoms

Headache, which may be:

Dull or throbbing All over or worse on the sides of the head On only one side of the head Severe or mild.

The headache commonly lasts 6 to 12 hours. Your child may also:

Have loss of appetite Feel sick - have nausea or vomiting Look pale Feel tired Have stomach pain.

Doctors can usually make the diagnosis of migraine after carefully listening to the story and examining your child. In a very small number of children, tests may be done to exclude other causes of headache. Most children do not need any tests, and there are no tests which prove the diagnosis of migraine.

Causes

Many things can trigger or start migraine headaches:

Being tired Bright lights Loud noises Relaxation after physical or mental stress Muscle tension over a long time Smoking, or breathing tobacco smoke Missing meals Drinking alcohol Caffeine (found in coffee, many energy drinks and some medicines) Menstrual periods Using oral contraceptives (the pill) Other conditions.

Food

In only a few children, migraine can be triggered or started by certain foods such as:

Food containing the amino acid tyramine (red wine, aged cheese, smoked fish, chicken livers, figs, some beans).

Chocolates Nuts Peanut butter Fruits (avocado, banana, citrus fruit) Onions Dairy products (milk, yoghurt, cheese) Baked goods Meats containing nitrates (bacon, hot dogs, salami, cured meats) Foods containing monosodium glutamate (MSG), an additive in many foods Any processed, fermented, pickled, or marinated foods.

However, for most children, changing the diet does not help.

Treatment

There is no cure for migraine. Anything that has triggered a migraine in the past should be avoided if possible. The goals of treatment are to control your child’s symptoms and prevent further migraines.

Care at home

Regular meals and sleep patterns are very important. Resting in a quiet, dark room may reduce how severe the symptoms are when a headache

happens. Paracetamol (Panadol, Dymadon, etc) may reduce pain if taken at the beginning of the

headache.

Alternative therapies, including relaxation techniques, can help some children. There are other drugs that can be used to treat attacks of migraine and also drugs that can be

used to help prevent attacks. Your doctor will discuss these with you. Most children do not need preventative drugs – ie drugs to stop the migraine starting. In

general, drugs to prevent migrane are only used for children who get very frequent migraine headaches that interfere with going to school etc.

Key points to remember

Migrane headache is painful and annoying at the time, but it is not usually a serious problem. There is no cure for migraine. Anything that has triggered a migraine in the past should be avoided if possible.

Head Injury Guideline

Assessment Level Of Consciousness - Glasgow coma scale Management

Minor Head Injuries Moderate Head Injury Severe Head Injury

Emergency Drug & Fluid Calculator

See also Major trauma guidelines

Head injuries are common in children of all ages. Causes include falls, sporting accidents, road traffic accidents and non-accidental injury.

Assessment:

Perform a primary survey and ensure that the child’s airway, cervical spine, breathing and circulation are secure.

Rapidly assess the child’s mental state using the AVPU scale. Use firm supraorbital pressure as the painful stimulus.

A Alert V Responds to voice P Responds to pain

Purposefully Non-purposefully

Withdrawal/flexor response Extensor response

U Unresponsive

Assess pupil size, equality and reactivity and look for other focal neurological signs.

View flowchart

Perform a secondary survey looking specifically at:

Neck and cervical spine – deformity, tenderness, muscle spasm Head – scalp bruising, lacerations, swelling, tenderness, bruising behind the ear (Battles sign) Eyes – pupil size, equality and reactivity, fundoscopy Ears – blood behind the ear drum, CSF leak Nose – deformity, swelling, bleeding, CSF leak Mouth –dental trauma, soft tissue injuries Facial fractures Motor function – examine limbs for presence of reflexes and any lateralising weakness Perform a formal Glasgow Coma Score Consider the possibility of non-accidental injury during secondary survey especially in infants

with head injury. Other injuries (see major trauma guidelines)

Gain as much information as possible regarding the incident. Specifically determine:

Time, mechanism and circumstances of injury Loss or impairment of consciousness and duration Nausea and vomiting Clinical course prior to consultation – stable, deteriorating, improving Other injuries sustained

Level Of Consciousness - Glasgow coma scale

Eye opening Verbal Response (modifications for small children in red)

Spontaneous 4 Orientated Appropriate words or social smile, fixes, follows 5

To speech 3 Confused Cries but consolable 4

To pain 2 Inappropriate words Persistently irritable 3

Nil 1 Incomprehensible words Restless & agitated 2

Nil Nil 1

Motor response

Obeys commands 6

Localises to stimuli 5

Withdraws to stimuli 4

Abnormal flexion 3

Extensor responses 2

Nil 1

Management

Minor Head Injuries:

No loss of consciousness One or less episodes of vomiting Stable, alert conscious state May have scalp bruising or laceration Normal examination otherwise

These children may be discharged from the Emergency Department to the care of their parents.

If there is any doubt as to whether there has been loss of consciousness or not, assume there has been and treat as for moderate head injury.

Ensure the parents have clear instructions regarding the management of their child at home especially to return to hospital immediately if their child:

becomes unconscious or difficult to rouse becomes confused has a fit develops a persistent headache repeatedly vomits develops any bleeding or watery discharge from the ears to nose

Give parents a Head Injury Parent Information Sheet to reinforce your advice.

Moderate Head Injury:

Brief loss of consciousness at time of injury Currently alert or responds to voice. May be drowsy Two or more episodes of vomiting Persistent headache Up to one single brief (<2min) convulsion occurring immediately after the impact May have a large scalp bruise, haematoma or laceration Normal examination otherwise

If, on the history from the parents and ambulance, the child is not neurologically deteriorating they may be observed in the Emergency Department for a period of 4 hours with 30 minutely neurological observations (conscious state, PR, RR, BP, pupils and limb power).

The child may be discharged home if there is improvement at 4 hours to normal conscious state and no further vomiting (child should be able to tolerate oral fluids in the Department). Head Injury Parent Information Sheet should be given to the parents.

A persistent headache, large haematoma or possible penetrating wound may need further investigation, discuss with consultant.

If the child is still drowsy or vomiting at 4 hours or there is any deterioration during this time, discuss with a neurosurgeon regarding admission and further investigation.

Severe Head Injury:

More than a brief loss of consciousness at time of injury Decreased conscious state – responsive to pain only or unresponsive CSF leak from nose or ears Localising neurological signs (unequal pupils, lateralising motor weakness) Signs of increased intracranial pressure:

Uncal herniation: Ipsilateral dilated non-reactive pupil due to compression of the oculomotor nerve

Central herniation: Brainstem compression causing bradycardia and hypertension Penetrating head injury Seizures (other than single brief (<2 min) convulsion occurring immediately after the impact)

Initial Management of Severe Head Injury:

Prevent secondary brain insults by maintaining a patent airway, adequate ventilation and oxygenation and avoiding hypotension.

Cervical spine immobilisation should be maintained even if the lateral cervical spine x-ray is normal.

Ensure early neurosurgical and ICU intervention. In consultation with the neurosurgeon consider measures to decrease intracranial pressure:

Nurse 20-30 degrees head up (only after correction of shock) Ventilate to a pCO2 35mmHg Consider mannitol 0.5-1g/kg IV Ensure adequate blood pressure

Control seizures (see Convulsions guidelines) Arrange urgent head CT.

Head injury

Children have many bangs to the head and it can be difficult to tell whether they are serious or not. If your child has received an injury to the head, you should see a doctor. A head injury is any knock to the head that causes lumps, bruises, cuts or more severe injuries to your child's head. Many head injuries are not serious and simply result on a bump or bruise. Occasionally head injuries can result in damage to the brain.

Seek medical help immediately if:

Your child has had a hard bang to the head, such as falling off something high or from a car accident.

Your child losses consciousness. Your child seems unwell and vomits several times after.

Signs and symptoms

The symptoms of head injuries are used to determine how serious it is. Head injuries can be classified into minor, moderate or serious.

A severe head injury is when your child:

Has lost consciousness for more than 30 seconds. Is drowsy and does not respond to your voice. Has other significant head injury signs, such as unequal pupils, arm and leg weakness. Has something stuck in their head. Has a second fit or convulsion, other than a single brief one when the injury happened.

You should call an ambulance immediately if your child has a severe head injury.

A moderate head injury is when your child:

Has lost consciousness for less than 30 seconds. Is alert and responds to your voice. Has vomited 2 times or more. Has a headache. One brief fit may have happened straight after the injury. May have a large bruise, lump or cut on the head.

Your child should be watched closely in hospital for at least 4 hours after a moderate head injury.

A minor head injury is when your child:

Has not lost consciousness. Is alert or interacts with you. May have vomited, but only once. May have bruising or cuts on their head. Otherwise normal.

Treatment of minor head injury

Most children with minor head injury make a full recovery. Most small knocks just cause bruising and pain for a short while.

Apply ice or a cool wash to the area injured to help reduce the swelling. If your child has a cut, apply a clean dressing and press on it for about 5 mins. Cuts to the

head will often bleed a lot.

Problems to watch for in the next day or two:

Headache. Your child may have a headache. Give paracetamol every 4-6 hours if needed to relieve pain

Vomiting. Your child may have vomited once but if vomiting continues, go back to your doctor.

Drowsiness. Immediately after the head injury your child may be sleepy. There is no need to keep your child awake if they want to sleep. If your child does go to sleep, wake them every half to one hour to check their condition, and their reaction to familiar things. You should do this until they are no longer drowsy and have been awake and alert for a few hours. Some questions you could ask are: - Do they know where they are? - Do they know familiar people’s names? - Do they know which day it is? - Or if they are very young: Do their reactions seem appropriate? ie. Reaching out for a dummy. Are they interactive and not too irritable?

If you have any difficulty waking your child, take them to the nearest emergency department or call an ambulance.

If your child's behaviour is very different to their normal behaviour, or the pain does not go away, go back to your doctor.

Follow up

Some problems that may result from a minor head injury can be hard to detect at first. In the next few weeks parents may notice:

Irritability Mood swings Tiredness Concentration problems in their child

Behavioural changes.

Talk to your doctor if you are worried about any of these signs.

Go back to your doctor or hospital immediately if your child has:

Unusual or confused behaviour. Severe or persistent headache which is not relieved by paracetamol (irritability in a baby). Frequent vomiting. Bleeding or discharge from the ear or nose. A fit or convulsion, or spasm of the face or arms or legs. Difficulty in waking up. Difficulty in staying awake. If you are worried for any reason.

Key points to remember

If your child has received an injury to the head, you should see a doctor. Apply ice or a cool wash to the area injured to help reduce the swelling.

Other sources of information

In an emergency call '000' for an ambulance. Preventing Falls (pdf)

Henoch-Schonlein Purpura

Introduction

HSP typically presents with the triad of

purpuric rash on the extensor surfaces of limbs (mainly lower) and buttocks, joint pain/swelling and abdominal pain.

Abdominal pain or arthralgia sometimes precede the rash.The commonest age group is 2 - 8 years. The cause is unknown but there may be a recent history of an upper respiratory tract infection.

Assessment

Purpura: If atypical distribution or the child is unwell, consider meningococcaemia, thrombocytopenia, or other rare vasculitides.

Joint Pain: Swelling and arthralgia of large joints are often the patient’s main complaint. In most situations this pain resolves spontaneously within 24-48 hours.

Abdominal pain: Uncomplicated abdominal pain often resolves spontaneously within 72 hours. However serious abdominal complications may occur including intussusception, bloody stools, haematemesis, spontaneous bowel perforation, and pancreatitis.

Renal disease: Haematuria is present in 90% of cases, but only 5% are persistent or recurrent. Less common renal manifestations include proteinuria, nephrotic syndrome,

isolated hypertension, renal insufficiency and renal failure (<1%). Renal involvement may only present during the convalescent period.

Subcutaneous oedema (scrotum, hands, feet, sacrum): This can be very painful. Rare complications - pulmonary and CNS involvement

Typical rash distribution

Investigations

Urine analysis should be performed, and if haematuria is present the sample should be sent for microscopy to quantify the RBC count.

Other investigations may include:

Full blood count Urea, electrolytes with creatinine Blood culture

Management

All patients presenting with a purpuric rash must be seen by a consultant or registrar, even if the child does not appear unwell.

Document the child’s blood pressure Consider a surgical consult if abdominal features are prominent. Testicular torsion can be

hard to differentiate from the pain of vasculitic testicular pain. There are some data to support the use of prednisolone. It may prevent the development of

long term renal complications. Consider prednisolone 1mg/kg for two weeks in all cases (not just those with haematuria). The use of prednisolone will also treat abdominal and joint pain and is particularly helpful for the oedema.

Indications for admission:

abdominal complication. Arrange early surgical consultation.

renal complication eg nephritis, nephrotic syndrome

Also consider admission for symptomatic treatment:

severe joint pain – treatment is bed rest and analgesia abdominal pain painful subcutaneous oedema

Disposition

Give the family a Parent Information Sheet on HSP

If discharged from the ED then it is imperative that appropriate follow-up is arranged to ensure adequate symptom control and resolution of the disease. Short term support can occur in the ED but follow-up care should soon be transferred to the GP (emphasise the need for ongoing BP and urine review in the letter) or a paediatrician - an appointment may be made in the General Medical Outpatient Clinic. The rash is usually the last manifestation to remit and appears to worsen if the child is very active. Some recommend an annual BP and urinalysis for life.

As the renal involvement can present up to six months after the initial presentation the urine should be checked regularly for that period. The blood pressure should be checked twice during that time. If the child has persistent renal involvement they should be referred to a paediatrician, or paediatric nephrologist for long term follow up.

Henoch-Schonlein Purpura (HSP)

What is Henoch-Schönlein Purpura (HSP)?

Henoch-Schönlein Purpura causes blood vessels to get inflamed (irritated and swollen). This inflammation is called vasculitis. It usually affects the small blood vessels in the skin causing a rash that is called purpura. It can also affect blood vessels in the intestines and the kidneys.

The cause of HSP is unknown. It might be triggered by bacterial or viral infections, medicines, insect bites, vaccinations or exposure to chemicals or cold weather. It occurs most often in the spring, usually after an upper respiratory infection, like a cold.

HSP usually affects children from two to ten years of age, but it can happen in anyone. HSP itself is not contagious. Doctors don't know how to prevent HSP yet.

Signs and symptons

Skin rash. The rash looks like small bruises or small reddish-purple spots. It's usually on the buttocks, on the legs and around the elbows.

Swelling. Many children with HSP also have swelling over the backs of the feet and hands, and the scrotum in boys.

Pain in the joints (such as the knees and ankles).

Stomach pain. Blood in the stool (poo) or urine, caused by the blood vessels in the bowel and the kidneys

becoming inflamed. Serious kidney problems don't happen very often, but they can occur. In rare cases, an abnormal folding of the bowel called intussusception can occur. This causes

a blockage in the intestines that may need surgery.

Treatment

There is no specific treatment for HSP. Medicines can help your child feel better or treat an infection that may have triggered HSP.

Fortunately, HSP usually gets better without any treatment. Painkillers (eg paracetamol) or anti-inflammatory medicines (eg ibuprofen) can help the joint pain. Your doctor may recommend a drug called prednisolone (cortisone). This can help people with severe stomach pains or very painful joints. It may also be helpful in preventing kidney problems.

Usually, HSP gets better on its own and doesn't cause lasting problems. About half of people who had HSP once will get it again. A few people will have kidney damage because of HSP. This may occur in the first week or so of illness, but there may be a delay of weeks or months before it appears. Your doctor will want to check urine samples and blood pressure several times after the HSP goes away to check for kidney problems. These checks should go on for at least six months and some doctors recommend a BP and urine check every year for life.

Key points to remember

HSP causes inflammation of the small blood vessels in the skin causing a rash. HSP can also affect blood vessels around the kidneys and intestines. HSP occurs most often in children from 2-10 years. The cause is unknown. Paracetamol and anti-inflammatory drugs help painful joints and general discomfort. Prednisolone may be prescribed. Return to your doctor for increasing pain,swelling, blood in the stools (poo) or urine or if you

are worried at all. Long term follow-up for urine and blood pressure checks are very important.

When to come back

Return to your doctor or the hospital if your child gets increasing stomach pains or swelling, blood in the stools or urine, or if you are worried for any other reason.

The Acutely Painful Hip

The causes of an acutely painful hip include many of the entities which must be considered for any acutely swollen joint (See Acutely Swollen Joint Guidelines). However there are several conditions which are unique to the hip and for which any child presenting with hip pain must be carefully evaluated.

Irritable Hip (transient synovitis)

Commonest reason for a limp in the pre-school age group. Usually occurs in 3-8 year olds

History of recent viral URTI (1-2 weeks) Child usually able to walk but with pain Child otherwise afebrile and well Mild-moderate decrease in range of hip movement - especially internal rotation. Severe limitation of hip movement suggests septic arthritis.

NOTE: Transient synovitis is a diagnosis of exclusion (see conditions below and Acutely Swollen Joint Guidelines). Symptoms of irritable hip overlap with those of septic arthritis, if there is any doubt as to the diagnosis then consultation with orthopaedics should be sought.

Perthes disease

Avascular necrosis of the capital femoral epiphysis. Age range 2-12 years (majority 4-8yrs) 20% bilateral Present with pain and limp Restricted hip motion on examination

Slipped Capital Femoral Epiphysis

Late childhood/early adolescence. Weight often > 90th centile. Presents with pain in hip or knee and associated limp. The hip appears externally rotated and shortened. There is decreased hip movement - especially internal rotation. May be bilateral.

Investigations

FBE Usually normal in the above conditions

ESR Usually normal in the above conditions

Xray Normal in transient synovitis

Density of femoral head, patchy osteolysis with variable degree of femoral head deformity in Perthes.

"Frog Lateral" x-rays of the affected hip will reveal slipped capital femoral epiphysis. Ultrasound

In consultation with orthopaedics -may show fluid in transient synovitis Bone scan

In consultation with orthopaedics. Disposition Children with transient synovitis may be managed with simple analgesics and bed rest.

Occasionally these patients may require admission for bed rest and traction.

All patients with Perthes disease and Slipped Capital Femoral Epiphyses should be referred to orthopaedics.

HSV Gingivostomatitis

See also: Specimen collection site IV fluid guideline

Pharmacopoeia on line

Background Assessment Diagnosis Management Analgesia Specific treatment Notes

Background

Primary Herpes simplex virus (HSV) infection in children is usually asymptomatic or non- specific. Herpetic gingivostomatitis is the most common specific clinical manifestation, occurring in 25% to 30% of cases

Condition is usually self limiting General course is 10 -14 days Virus readily transmitted through direct contact Ensuring adequate hydration and analgesia are the mainstays of treatment There is little role for the use of antiviral medications except in certain circumstances

Assessment

See flow chart

Diagnosis

The diagnosis is clinical in the majority of cases Typical herpetic gingivostomatitis usually does not require lab confirmation Where confirmation is required (immunocompromised host or contact), direct

immunofluorescence (DIF) and cell culture of scrapings from the base of the lesion should be performed (See how to take swab for HSV)

Serology is rarely helpful

Management

See flow chart

Analgesia

Pain relief is of paramount importance in HSV gingivostomatitis

Topical analgesics are effective but may be expensive eg Xylocaine Viscous®, Lignocaine gel 2%®

Regular analgesics such as paracetamol seem to have little effect, although Codeine containing medications may be beneficial eg Painstop®

Specific Treatment

Aciclovir is not recommended in immunocompetent hosts with typical herpetic gingivostomatitis

Topical aciclovir is generally not effective Specialist advice should be sought regarding immunocompromised patients

Notes

Central nervous system involvement, although rare, can occur with HSV and should be considered in patients who are unusually lethargic or who have abnormal neurological findings see flow chart

Appendix

HSV Stomatitis flowchart

Specimen collection guide for Herpes Simplez & Varicella Zoster virus detection

Material required: (Available from the RCH Virology Lab 8th floor)

1. Two sterile swabs 2. One vial of Viral Transport Medium, (pink medium) 3. One painted 3-well glass microscope slide.

Method of collection:

1. Puncture the vesicle with a sterile swab / needle. 2. Collect as much of the vesicle fluid as possible by absorbing onto a sterile dry swab. (Shown

in Diagram 1)

3. Immediately immerse and break the swab into Viral Transport Media for viral isolation studies.

4. After the vesicular fluid is removed for isolation, lift the loose flap of skin and roll the second

sterile swab back and forth across the base and under the flap. Holding a clean 3 well slide by the frosted end, painted side up, smear the sample onto the wells. Use a circular motion and a new surface of the swab for each well. (Shown in Diagram 2).

5. Immerse and break the second swab into Viral Transport Medium for viral isolation studies.

Hydrocarbon Poisoning

See also General Management of Acute Poisoning Guideline

Hydrocarbons Include: Petrol Kerosene Lighter Fluid Mineral Turpentine Paraffin Oil

Lubricating Oil Furniture Polishes 2 Stroke Fuel Dielsel Fuel White Spirit

Assessment

main complication is Aspiration Pneumonitis C.N.S. toxicity can be evident (either depression or excitement)

Symptoms: coughing, choking, respiratory distress ataxia, drowsiness, coma, convulsions persistent burping (particularly seen after petrol ingestion)

Management

Keep nil orally charcoal is contraindicated

a. Asymptomatic o Observe 6hours o Discharge if remains asymptomatic o Arrange review by LMO the following day

b. Symptomatic o If develops respiratory symptoms (aspiration), do CXR & O2 saturation o Give O2 to maintain saturation > 94% o If stable, admit to general medical ward o If increasing O2 requirements or increased respiratory distress contact I.C.U. (5212) o If altered conscious state at any time contact I.C.U. (5212)

Hypernatraemia

Definition

Hypernatraemia is defined as a serum [Na+] > 150mmol/l.

Definition

Serum [Na+] (mmol/l)

Hyponatraemia < 135

Normal 135 - 149

Moderate Hypernatraemia 150 - 169

Severe Hypernatraemia > 169

Background

Uncommon in Paediatrics, it can be either secondary to

Water loss in excess of sodium (Most common) Diarrhoea, especially with continuing hyperosmolar feeding (such as Polyjoule) Severe burns Impaired renal concentrating ability (osmotic diuresis)

Water deficit Inability to obtain/swallow water Impaired thirst drive (e.g. Hypothalamic lesion) Diabetes insipidus

Gain of sodium Ingestion of large quantities of sodium (inappropriate making up of formula/home

made rehydration solution) Iatrogenic sodium administration (hypertonic saline, sodium bicarbonate)

If the cause of the hypernatraemia is central diabetes insipidus contact the Endocrinology team for advice on management.

Assessment

Signs are more severe with acute rapidly developing hypernatraemia than with chronic hypernatraemia. Chronic hypernatraemia is often well tolerated because of cerebral compensation.

Severe symptoms mainly develop when the serum [Na+] > 160mmol/l.

Signs

The true degree of dehydration (as assessed by recent weight loss) is often underestimated if an assessment is based on external clinical signs of dehydration alone. In hypernatraemia the child appears sicker than expected for the clinical signs of dehydration that are present. Shock occurs late because intravascular volume is relatively preserved. Signs of hypernatraemic dehydration tend to be predominately those of intracellular dehydration and neurological dysfunction:

Lethargy Irritability Skin feels "doughy" Ataxia, tremor Hyperreflexia, Seizures, reduced GCS

Management

If the patient is "shocked", volume resuscitation with 0.9% saline as required with 20ml/kg bolus/es.

Too rapid reduction of the sodium in hypernatraemia can cause cerebral oedema, convulsions and permanent brain injury. The aim is to lower the serum [Na+] slowly at a rate of no more than 12mmol/L in 24 hours, (0.5mmol/L/hour).

A slower rate will be required for children with chronic hypernatraemia (present for more than 5 days).

Calcium and glucose need to be checked as hypernatraemia, can be associated with hypocalcaemia and hyperglycaemia, these conditions need to be corrected concurrently.

Moderate hypernatraemic dehydration, [Na+] 150 - 169 mmol/L.

After initial resuscitation, replace the deficit plus maintenance slowly at a uniform rate over 48 hours.

Use nasogastric oral rehydration solution (Gastrolyte), but remember that Gastrolyte has a sodium concentration of 60mmol/L. Carefully regulate fluid intake, do not rely on the child or parent to regulate intake. If the serum sodium falls too rapidly slow the rate or rehydration or change to intravenous fluids.

If needing intravenous rehydration use 0.45% NaCl + 5% dextrose or 0.9% NaCl + 5% dextrose. Add maintenance KCl once urine output established.

Check U&E's and glucose one hourly, if serum sodium is falling faster than 1 mmol/hr slow rate of infusion by 20%. Recheck the serum sodium in 1 hour. If after 6 hours of rehydration therapy the sodium is decreasing at a steady rate then check the U&Es and glucose 4 hourly.

If there are persistent neurological signs then consider cerebral imaging.

Severe hypernatraemic [Na+] > 170

Contact and consider admission in PICU.

After initial resuscitation, aim to replace deficit and maintenance with 0.9% NaCl + 5% dextrose over 72 - 96 hours.

Table for fluid replacement when hypernatraemia is associated with dehydration

Weight (kg)

Moderate hypernatraemia (serum [Na+] 150 –169) Rate of fluids ml/hr, using 0.45% NaCl+ 5% dextrose(replacing deficit over 48hrs) (calc on 7% dehydrated)

Severe hypernatraemia (serum [Na+] > 170)Rate of fluids ml/hr, using 0.9% NaCl +5% dextrose(replacing deficit over 96hrs) (calc on 10% dehydrated)

4 22 21

5 27 25

6 33 30

7 38 35

8 44 40

10 55 50

12 62 56

14 68 62

16 75 68

18 82 75

20 90 80

22 96 87

24 100 90

26 105 95

28 110 98

30 114 100

32 120 105

34 124 110

36 128 113

38 133 117

40 138 122

45 150 132

50 160 142

55 175 152

60 187 162

65 195 168

70 200 173

Notes

If seizures or other signs of cerebral oedema occur during treatment, check the serum sodium. If there has been a rapid fall it may be necessary to give hypertonic saline to partially reverse the reduction in serum sodium. Seizures may be due to venous sinus thrombosis or cerebral infarction. Do a contrast CT scan.

Consider peritoneal dialysis if the serum [Na+] > 180mmol/l.

Measure ongoing losses (except urine) and replace ml for ml with normal saline.

Hypertension

Upper 95th Centile for BP

Age Systolic Boys

Diastolic Boys

Systolic Girls

Diastolic Girls

6 114 74 111 74

7 115 77 113 76

8 116 79 115 78

9 118 80 117 79

10 119 81 119 80

11 121 81 121 80

12 123 82 123 81

13 126 82 124 81

14 128 83 126 82

15 131 83 127 83

16 134 84 128 84

17 136 87 129 87

These values are for children on the 50th centile for height

BP Centile Charts

Boys Chart

Girls Chart

Note: BP measurements repeated on several different occasions are required to diagnose hypertension. The cuff bladder should cover at least 3/4 of the child’s arm length, and the child should be quiet and calm.

Causes

Essential hypertension

Obesity may complicate the accurate measurement of blood pressure and be a contributing factor.

Secondary causes

Renal (75%) - post-infectious glomerulonephritis, chronic glomerulonephritis, obstructive uropathy, reflux nephropathy, reno-vascular, haemolytic uraemic syndrome, polycystic kidney disease

Cardiovascular (15%) - coarctation of the aorta

Endocrine (5%) - phaeochromocytoma, hyperthyroidism, congenital adrenal hyperplasia, primary hyperaldosteronism, Cushing syndrome

Other (5%) - neuroblastoma, neurofibromatosis, steroid therapy, raised intracranial pressure.

Assessment

Appearance - Cushingoid, obese Height and weight Upper and lower limb BP measurement Skin: Cafe-au-lait spots, neurofibromas, hirsutism, vasculitis Fundoscopy: hypertensive retinopathy CVS examination: left ventricular hypertrophy, murmurs (particularly interscapular) Abdomen: renal / adrenal masses, renal bruits Full neurological examination

Investigation

Initially: urine analysis, urine microscopy, urea and electrolytes, creatinine

Further investigations may include: urinary catecholamines, chest X-ray, ECG, renal ultrasound, gluconate scan, plasma renin pre- and post- captopril, thyroid function tests, cortisol / aldosterone levels, 17-hydroxy progesterone, renal angiography.

Management

Asymptomatic hypertension

No treatment required acutely. Investigate and manage as out-patient. Refer to General Paediatric Outpatient Clinic.

Acute severe hypertension

These patients require admission to ICU for urgent treatment.

Hypertensive encephalopathy presents as severe headache, visual disturbance and vomiting, progressing to focal neurological deficits, seizures and impaired conscious state, with grossly elevated BP, papilloedema and retinal haemorrhages. These patients almost always have chronic renal disease and are on dialysis. The differential diagnosis includes uraemic encephalopathy and metabolic disturbance. BP should be lowered in a controlled fashion, with anticonvulsants given for seizures.

Antihypertensives

Choice includes (list not exhaustive):

Sublingual / oral nifedipine: tabs - 0.5 - 1.0 mg/kg/dose (max. 40 mg) 12-hourly Side effects include tachycardia, flushing and fluid retention.

Intravenous labetalol: 0.2 mg/kg initially; later 0.4 mg/kg by slow push every 10 min up to 3 - 4

mg/kg (max. 100 mg) total dose. Avoid if there is heart failure, asthma or bradycardia.

Intravenous hydralazine: 0.1 - 0.2 mg/kg (max. 10 mg) stat, then 4 - 6 micrograms/kg/min (max

300micrograms/min). Hydralazine may cause tachycardia, nausea and fluid retention.

Oral captopril: 0.1 mg/kg initially, increasing to a maximum of 1 mg/kg (max. 50 mg). Thereafter 0.1-1.0 mg/kg/dose 8-hourly. Captopril is usually effective within 30 - 60

min.

Pyloric Stenosis

See also: Diarrhoea & Vomiting

Background

Hypertrophic Pyloric Stenosis (HPS) is due to progressive thickening of the circular muscle of the pylorus. This leads to gastric outlet narrowing.

The condition usually presents between 2 and 6 weeks of age.

Risk Factors:

Male Firstborn Caucasian Parental history of HPS (higher if mother affected)

Assessment

History:

Vomiting progressively more forceful and may be projectile non-bilious blood stained in up to 10% of cases

Usually don't have diarrhoea Often hungry afterwards Weight loss or inadequate weight gain

Examination:

Assess degree of dehydration Weigh and plot on growth chart with previous weights if available Look for jaundice (1-2% of infants with HPS) Look for gastric peristalsis (waves of muscle contraction across the abdomen passing from

the left upper quadrant to the right lower quadrant). Feel for a pyloric mass (best felt in the right upper quadrant with the infant supine.

Approximates the size and shape of an olive. Best felt from left side. Wait for several minutes.)

Signs may be more obvious following a feed

Investigations:

Take blood for FBE, U&E, Acid-Base, Glucose (bilirubin if jaundice present) Hypochloraemic Hypokalaemic Metabolic Alkalosis may be seen.

If diagnosis not yet established, abdominal ultrasound is the investigation of choice (95% sensitive).

Management

Fluid resuscitation may be necessary with 10-20ml/kg boluses of normal saline, for patients with moderate to severe dehydration

Commence IV Fluids (0.45% Saline / 5% Dextrose + 10mmol KCl / 500mls) at 100mls/kg/day initially. Review after 4-6 hours (see below).

Stop oral feeds Insert a nasogastric tube if vomiting continues despite stopping feeds. Replace nasogastric

losses with IV normal saline Repeat U&E, Acid-Base 4-6 hourly initially and adjust fluid accordingly. The aim for most

infants should be to fully correct fluid and electrolyte deficits within 48 hours. Initial KCl may be required if significant hypokalaemia Replace deficit, in addition to maintenance, in those infants who are clinically dehydrated

(weight is a good marker of the degree of dehydration)

Notes

Correction of HPS is not an emergency, and should not be undertaken until normal electrolytes and pH have been restored and the infant is rehydrated

It is particularly important to fully correct serum bicarbonate before theatre because of the risk of hypoventilation/ apnoeas post-operatively in the setting of metabolic alkalosis.

Operation is Ramstedt's Pyloromyotomy (may be done laparoscopically in some cases) Feeding is usually restarted within 6 hours post-op. Some children will continue to vomit for

several days. Infants are usually discharged within 3 days. Re-stenosis can occur, but is uncommon (1-2%). See Parent handout

Pyloric Stenosis flowchart

...

Hypoglycaemia Guideline

Background

Beyond the neonatal period, hypoglycaemia is defined as a blood glucose less than 2.5mmol/l.

There should be a low threshold for performing a dextrostix in the acutely unwell child.

Assessment

Effects

CNS Effects - irritability, coma, depressed level of consciousness, convulsions.

Adrenergic overdrive - tremor, jitteriness, pallor, sweating.

Causes

Measure height and weight. Look for midline defects, micropenis, optic nerve hypoplasia (hypopituitarism), cataracts (galactosaemia), hepatomegaly (glycogen storage disease) and hyperpigmentation (adrenal insufficiency).

Hemihypertrophy, exomphalos, macroglossia and transverse ear creases (Beckwith syndrome).

Investigation

Blood

Glucose and lactate: fluoride oxalate tube, 1ml Insulin, cortisol, growth hormone: plain tube (2-4 ml) Ammonia: heparinized tube (1ml) Ketones and free fatty acids: fluoride oxalate (BLF) tube (1ml) Amino acids, electrolytes: heparinised (1-2ml) - if enough blood available Acid-base: capillary sample Blood drops onto a Guthrie test card (for acyl-carnitine profile)

Urine

Ward test for ketones, glucose, reducing substances 10-20ml for amino acids and organic acids

Management

Symptomatic hypoglycaemia should be treated with an i.v. bolus of 1-2ml/kg 25% Dextrose (0.25-0.5g/kg Dextrose). The expected maintenance infusion rate is 3-5ml/kg/hr of 10% Dextrose (6-8mg/kg/min). A required infusion rate of 10-20mg/kg/min is consistent with hyperinsulinism.

All patients with hypoglycaemia presenting to Emergency require admission.

Notes

Hyperinsulinism is the commonest cause of hypoglycaemia under two years old. This diagnosis is excluded by ketonuria.

"Accelerated starvation" (ketotic hypoglycaemia) classically manifests itself between the ages of 18 months and 5 years, and generally remits spontaneously before 8 or 9 years of age. A presumptive diagnosis is made by documenting a low blood sugar in association with ketonuria, ketonaemia and typical symptoms of hypoglycaemia. The definitive diagnosis is established by demonstrating an inability to tolerate a provocative ketogenic diet, or a fast. Susceptible or affected children develop severe hypoglycaemia and ketosis on this diet within 24 hours.

Hyponatraemia

Definition

Hyponatraemia is defined as serum sodium <135mmol/L. It represents an excess of water in relation to sodium in extracellular fluid. Symptoms are likely with Na <125 mmol/L or if the serum sodium has fallen rapidly.

Background

The main causes of hyponatraemia in children are:

Administration of hypotonic fluids, intravenous or enteral (e.g. excessively dilute formula or 0.18% NaCl)

Conditions with impaired free water excretion and high anti-diuretic hormone levels Meningitis, encephalitis, pneumonia, bronchiolitis, sepsis Surgery, pain, nausea and vomiting

Gastrointestinal fluid losses

Less common but important causes are:

Adrenal insufficiency (Congenital Adrenal Hyperplasia, Addison's Disease ) Defect in renal tubular absorption, including obstructive uropathy Psychogenic polydipsia

Prevention

Special attention should be paid when administering intravenous fluid to children with conditions associated with high ADH levels and impaired free water excretion (see above). (see IV Fluids guideline)

Never give 0.18% NaCl or 5% dextrose in water iv as maintenance fluids Give enteral feeding, rather than iv fluids, wherever possible, and include the volume of

enteral fluid in calculations of fluid intake. Use 0.9% NaCl (normal saline) plus dextrose as 'maintenance fluid' for any child who has:

A brain injury of any sort (meningitis, encephalitis, trauma, febrile convulsion) Any other condition associated with impaired free water excretion (see above) where

the child has a serum sodium of <138mmol per L. Give fluid volumes that take into account the reduced volumes required in children with

impaired free water excretion. For children who are on more than 50% iv maintenance fluids check the serum electrolytes

prior to starting fluids and at least once in the following 12 hours. Electrolytes may need to be checked more frequently if the starting sodium was abnormal. Pay attention to major changes in sodium even when it is still within normal range.

Assessment

Most children with mild to moderate hyponatraemia are asymptomatic or manifest the symptoms of the underlying disease (bronchiolitis, meningitis etc). The symptoms and signs of severe hyponatraemia are predominately neurological:

Headache Nausea, vomiting Lethargy or irritability Hyporeflexia Decreased conscious state Seizures

Assess the patient's hydration state. (see Gastroenteritis guideline)

If Na+ <130 mmol/L: measure serum potassium, chloride, urea, creatinine and glucose.

Measure the urinary sodium and osmolarity.

In the presence of hyperlipidaemia (e.g. nephrotic syndrome) or hyperpoteinaemia, some laboratories produce falsely low measurements of serum sodium (this is not the case at RCH). This is sometimes called pseudohyponatraemia. Contact your laboratory.

Management

The ideal rate of serum sodium correction depends on the presence and severity of symptoms. Correction that is too rapid (>8 mmol/L Na+/24h) can result in cerebral demyelination, especially of the pons, with risk of severe and lasting brain injury. This is especially a risk if hyponatraemia has been present for more than 5 days and is rapidly corrected.

The hyponatraemic child with seizures or CNS depression

Notify ICU urgently. Resuscitation (ABC) and intravenous anticonvulsants as clinically indicated. Hyponatraemic

seizures often respond poorly to conventional anticonvulsants, and sodium correction should not be delayed. The sodium should be raised until it reaches 125mmol/L or until seizures stop, whichever occurs first.

Use intravenous 3% NaCl solution. It is stored in the resuscitation trolleys on the wards, in the ICU and ED. Give 4ml/kg of 3% NaCl. Give over 15-30 minutes. This will raise the serum sodium by 3 mmol/L and will usually stop the seizures. 3% saline is hypertonic and should be given through a central venous line where possible.

Measure the serum sodium after the first bolus. Ongoing seizures and persistent hyponatraemia will require more 3% NaCl.

Many children with hyponatraemia and seizures will have other reasons for seizures (fever, meningitis, hypoglycaemia), and these should also be addressed

After the seizures have resolved the total sodium correction (including the bolus) should not exceed 8 mmol/L per day (e.g. from 122-130mmol/L).

Measure electrolytes every 2 hours until stable, then every 4-6 hours until the serum sodium is normal and the child is off iv fluids

The child with no symptoms of hyponatraemia

Management of children without specific symptoms of hyponatraemia depends on volume status. They may be normally hydrated, moderately dehydrated or severely dehydrated (see Gastroenteritis guideline).

Active correction of hyponatraemia (e.g. with 3% NaCl) is not necessary. Allow the plasma sodium concentration to rise at no more than 8 mmol/L per day using the guidelines below, based on hydration state. Continue correction to 135 mmol/L.

1. The child with normal or increased volume status

Restrict water to slowly remove the increased body water. Do not use hypotonic solutions (see prevention, above) See, for example, meningitis fluid guidelines.

2. The child with moderate dehydration and serum sodium 130-135mmol/L

Try nasogastric rehydration. When using Gastrolyte, remember that it contains 60mmol/L of sodium; rapid re-hydration may make the Na+ fall faster than is safe.

If NG rehydration is not possible or results in a too rapid fall in sodium give iv 0.9% NaCl (see severe dehydration below).

3. The child with severe dehydration or serum sodium <130mmol/L

Give iv 0.9% NaCl (plus 5% glucose) until the child can take enteral feeds.

Measure electrolytes every 4 hours until stable, whether on iv or nasogastric rehydration.

Hyponatraemia and severe hyperglycemia

Hyponatraemia occurs because high plasma glucose increases serum osmolarity, causing a shift of water from the intracellular space into extracellular fluid. The reduction in blood glucose after beginning treatment may correct the hyponatraemia, through a shift of water back to the intracellular space. However if the serum sodium fails to increase as the glucose falls hyponatraemia should be actively corrected. This will prevent a reduction in serum osmolality, which carries an increased risk of cerebral oedema. Using 0.9% NaCl solution as the fluid for DKA resuscitation will generally maintain the osmolarity. (see DKA guideline).

Idiopathic Thrombocytopenic Purpura

Background

ITP is an acquired thrombocytopenia due to immune mediated shortened circulating platelet survival in the absence of other disturbances of haemostasis or coagulation. In most childhood ITP platelet autoantibodies are absent.

Patients fall broadly into two categories:

1. Acute (~ 90%): self limiting disease (sometimes preceded by a viral syndrome) with spontaneous resolution within 6 months (usually within 2 months).

2. Chronic (~ 10%): does not remit within 6 months.

Most children present with bruising and petechiae alone. In some instances there is oral bleeding, epistaxis, rectal bleeding or haematuria. Morbidity in ITP is usually minimal and parents need to be reassured of this. The incidence of intracranial haemorrhage is much less than 1%, and very rare in true

uncomplicated ITP.

Assessment

The clinical diagnosis of ITP depends on there being manifestations of thrombocytopenia without other abnormal findings, in particular no pallor, lymphadenopathy or hepatosplenomegaly.

Confirmation rests on the adequate exclusion of other causes of thrombocytopenia. The most important conditions to exclude are acute leukaemia, other marrow infiltrative conditions and aplastic anaemia. An FBE (including blood film) will usually confirm the diagnosis.

A bone marrow aspirate is an invasive procedure with some morbidity in children who bruise easily, and is only necessary if the diagnosis is uncertain. It is rarely necessary in uncomplicated ITP.

Management

Initial treatment options include no treatment and oral steroids.

Without active treatment, most patients platelet counts will return to a level at which normal activity can be recommenced within 4-6 weeks. Oral steroids bring up the platelet count more quickly than occurs spontaneously but there is no evidence for an effect on significant morbidity, risk of chronic ITP, or mortality.

At RCH, the on-call General Paediatric consultant is responsible for deciding on the treatment plan.

a) Conservative Outpatient Management

Most patients with a platelet count > 20,000 x 106/l and some of those with a platelet count < 20,000 x 106/l can be managed as outpatients with no specific treatment. The following criteria must be met:

The diagnosis is unequivocal. No pallor, hepatosplenomegaly or lymphadenopathy; isolated thrombocytopenia without anaemia, leucopenia or blood film changes.

There is no active bleeding. Bruising and petechiae in isolation, without mucosal, gastrointestinal or renal tract bleeding.

The child is otherwise well. Social circumstances allow confidence about the degree of parental supervision and relative

safety of the home environment, particularly for younger children. There is ample opportunity for parental reassurance and education in the Emergency Dept. Follow up is guaranteed within a few days by the on call General Paediatric consultant, who

must be contacted and agree with the management plan.

b) Conservative Inpatient Management

a. If the diagnosis of ITP is not certain (eg. the blood film result is not available) or any other of the above criteria are not met, then admission under the General Medical unit of the day is necessary.

b. The decision as to whether to treat patients who do not have active bleeding will be made by the unit consultant.

Treatment As An Inpatient

a. Any patient with ITP who has active bleeding (oral, aural, nasal, rectal, etc) even if resolved should be admitted and considered for oral prednisolone (2-4 mg/kg/day for 2 weeks then tapered).

Normal human immunoglobulin is also effective but is not usually used for initial treatment (Administration of Intragam Guideline) Avoid aspirin and non-steroidal anti-inflammatory drugs.

Notes

Acute, relapsing ITP

In some cases, thrombocytopenia will redevelop months or years after the first episode has resolved. These relapses or recurrences are usually precipitated by viral infections. Provided the first episode remitted spontaneously without complication and the patient has been well with a documented normal platelet count between episodes, these cases can be managed as for acute ITP.

Chronic ITP

Ongoing thrombocytopenia after a 6 month period denotes chronic ITP. A history of bruising from infancy should prompt suspicion of one of the rare congenital thrombocytopenias. Careful inspection of the blood film and tests of platelet function will serve to exclude other diagnoses. Bone marrow examination may behelpful in confirming chronic ITP.

Rarely, splenectomy is required (success rate 70-80%).

Idiopathic Thrombocytopenic Purpura (ITP)

ITP is a bleeding disorder resulting from a shortage of platelets in the blood. Platelets are the blood cells that help clot the blood, and if a child has a shortage of platelets then he or she will bruise easily and may have other bleeding problems.

The disease is caused when the spleen and lymph tissues produce antibodies against platelets. Antibodies are proteins that are produced by the immune system. The antibodies destroy the platelets in the spleen. We do not fully understand why the body produces this reaction. In children, the disease is sometimes preceded by a viral infection (eg a cold), and this seems to be a trigger for the production of abnormal antibodies.

ITP is more common in children than adults. ITP occurs in 1 out of every 10,000 children, so it is still quite rare.

It is important for you to know that the risk of any serious complication from ITP is very low.

In most children the condition will settle down quite quickly. The platelet count is often up to safe levels within a week or two, but it may take longer to fully return to normal. In a very small number of children the platelet count does not return to normal even after 6 to 12 months, and further treatment may be advised.

Signs and symptoms

Bruising Nosebleeds or mouth bleeding Petechial rash (pinpoint red spots) on the skin

Treatment

There are several treatment options which your childs doctor will discuss:

No treatment - this is a good option for many children. The condition will get better spontaneously.

Steroids (prednisolone) - this can raise the platelet count more quickly than would occur with no treatment.

Intravenous gamma globulin - sometimes used, but may have side effects

Your doctor will discuss the best treatment option for your child. You may need to attend for blood tests every few days to monitor the progress of the condition. It is important that you attend follow up appointments.

Care at home

Children with ITP should not take aspirin or ibuprofen (another pain killer), because this may provoke bleeding. Paracetemol is quite safe.

While the platelet count is very low, your child may be advised to not do activities which might cause bruising or bleeding (eg stay off the climbing equipment, bicycles etc) .

As the platelet count rises, more activity will be allowed, but contact sports, cycling and other rough physical activity may need to be avoided until your child's doctor advises.

Key points to remember about ITP

Bleeding disorder when the blood has difficulty clotting because of a shortage of platelets More common in children than adults Most cases will settle quickly with no treatment Serious complications are very rare

Current Immunisation Schedule (from 1 November 2005)

Birth HepB

2 months

DTPa-IPV (Infanrix-

IPV)

Hib-HepB (Comvax)

Pneumococcal (Prevenar)

Rotavirus (Rotateq)7

4 months

DTPa-IPV (Infanrix-

IPV)

Hib-HepB (Comvax)

Pneumococcal (Prevenar)

Rotavirus (Rotateq)

6 months

DTPa-IPV (Infanrix-

IPV) 1 Pneumococcal

(Prevenar) Rotavirus (Rotateq) 6

12 Hib-HepB MMR Meningo

months (Comvax) (Priorix) C 2 (Neisvac C)

18 months Varicella

(Varilrix) 3

4 years DTPa-IPV (Infanrix-

IPV) MMR

(Priorix)

year 7 HepB 5 Varicella (Varilrix) 4

year 10 dTpa (Boostrix)

1. Premature infants require an additional vaccine at 6 months: infants born < 28 wks give Hib-hepB; infants born 28 - 32 wks give HepB

2. Meningococcal C vaccine is funded for all 1-19 year olds. It can be given < 1 yr but is not currently funded (2-6 mo 3 doses; 6-12 mo 2 doses).

3. Varicella vaccine is funded for infants aged 18 months. It can be given at 12 months of age on the same day as MMR vaccine or 4 weeks later.

4. A catch-up dose of varicella vaccine is given to students in Year 7 who have not had chickenpox or varicella vaccine.

5. Adolescents aged 11-15 years who have not previously had hepatitis B vaccine are given 2 doses 4-6 months apart (using adult formulation).

6. Influenza vaccine can be given to any infant > 6 months. Children in certain risk groups are highly recommended annual influenza vaccine. Children < 9 years require 2 doses in the first year they receive the vaccine. Doses vary according to age - see The Australian Immunisation Handbook 8th Edition page 170.

7. Routine catch-up of primary vaccination is not recommended, do not give rotavirus vaccine beyond the following age limits, 1st dose by 12 weeks of age and 3rd dose by 32 weeks of age. Minimum interval between doses is 4 weeks.

^ Back to schedule

See also

Immunisation Handbook 8th Edition online Immunisation fact sheets for parents and providers Summary of recent changes to the schedule

New Vaccines Rotavirus vaccine fact sheet (for providers)

The Rotavirus vaccine was registered for use in Australia last year, and the Pharmaceutical Benefits Advisory Committee (PBAC) recommended it be included in a National Immunisation Program. It is likely that the vaccine will be funded and commence as part of the National Immunisation Program in 2008. Administration of a course of Rotavirus vaccination is recommended for all infants in the first

half of the first year of life, and currently this can be purchased from a pharmacy with prescription or by sending the patient and family to the RCH Immunisation Service.

HPV vaccine fact sheet (for parents) HPV vaccine fact sheet (for young women) HPV vaccine fact sheet (for providers)

The Human Papilloma Virus (HPV) vaccine is registered for boys aged 9-15 years and girls aged 9-26 years. There is no current funding for boys and from April 2007 the Australian Government is funding the vaccine for girls and women aged 9-26 years. The following age categories will be targeted from April 2007;

12-13 years as part of a Year 7 secondary school program (which will be ongoing) 13-18 years (catch-up secondary school immunisation program, funded for 2 years) 18-26 years (catch-up funded for 2 years)

Opportunistic Immunisation Guideline

See also:

Recommended Immunisation Schedule (Immunisation Service Home page) Immunisation Resources for Clinicians Immunisation Parent Information

Catch-up immunisation schedule for newly arrived refugees

Children who are due or overdue for their immunisations can be safely and effectively immunised during their hospital stay or at the time of an outpatient presentation.

Background How should we do it? Where should we do it? Immunisation procedure

Background

8-10% of Australian infants, and up to 15% of older children are not up-to-date with their immunisations

All vaccines can be safely given while an inpatient. Oral polio should be given at the time of discharge, or IPV (injectable polio vaccine) can be used.

How should we do it?

All children presenting to the hospital should have an immunisation history taken. If parents are unsure about previous immunisations check the child’s Personal Health

Record (yellow book) or contact the Australian Childhood Immunisation Register (ACIR) on 1800 653 809 (NB parent’s consent and child’s Medicare number are required for this)

Children who are not up-to-date should be offered the appropriate vaccines while still in hospital.

True contraindications to immunisations are very rare, and can be discussed with a nurse from the Immunisation Service.

See Catch-up immunisation for information on planning a catch-up schedule

Where should we do it?

In the Emergency Department

All vaccines on the schedule are available in the after hours drug room (in the fridge) Immunisations and their batch numbers should be documented on Treatment orders sheet.

In Outpatients

Children can be immunized in the Immunisation Drop-in Centre near the front entrance during working hours

Contact the Immunisation nurses on ext 6599 or page 4330 (intranet only)

On the Wards

All vaccines can be obtained from pharmacy Immunisations and their batch numbers should be documented on standard Drug charts

Immunisation Procedure

For Immunisations on the Schedule

1. Assess for contraindications — run through Pre-immunisation checklist 2. Obtain consent from parents (print out parent information sheets if desired) 3. Write vaccine on drug chart or emergency treatment orders 4. Obtain vaccine (see above) 5. Administer vaccine 6. Complete child’s yellow book, or give parents a letter with names and batches of vaccines

given 7. Complete notification form to ACIR

o Hospital notification form (complete for all immunisations given in the hospital and forward to the immunisation service) — information will be forwarded to ACIR. NB notification form is provided with immunisations which are supplied by the pharmacy, or can be printed.

o Australian Childhood Immunisation Registry (ACIR) form (for immunisations provided outside the hospital)

o NB if outside the hospital, and ACIR forms are not available — print off a copy of the hospital notification form, and fax or post to ACIR (FAX 08 9214 8163)

Vaccines not on the schedule (eg Rotavirus)

1. Is child eligible for hospital to fund vaccine? Discuss with consultant and /or Immunisation Service.

2. If so — obtain DUC (drug usage committee) approval 1. DUC form (intranet only)

Department funded Vaccines 2. Form checked by immunisation service. Contact the Immunisation nurses on ext

6599 or page 4330. (intranet only) 3. Immunisation provided as above

3. If child is not eligible, and parents wish to purchase vaccine these can be obtained via the immunisation centre. Contact the Immunisation nurses on ext 6599 or page 4330. (intranet only)

Intravenous Immunoglobulin

Intravenous Immunoglobulin (IVIG) is used in the management of an increasingly wide range of diseases. IVIG is primarily used as a source of antibody replacement in primary immunodeficiencies and to modulate the immune system in autoimmune and inflammatory diseases.

About the products

Intragam P is the primary IVIG supplied within Australia and is manufactured by CSL from the plasma of Australian volunteer blood donors. Due to a marked and sustained increase in the use of IVIG, CSL is no longer able to supply enough Intragam P to meet demand. The National Blood Authority has sourced an overseas IVIG (Octagam) that will be utilised during times of shortage of Intragam P. Octagam is now stocked and distributed by the Australian Red Cross Blood Service (ARCBS).

Patients currently receiving Intragam P for ongoing conditions will continue to receive Intragam P whenever possible. New patients will be issued either Intragam P or Octagam depending on availability of stocks, with an attempt to maintain individual patients on the same products.

Patients with IgA deficiency should be prescribed Intragam P.

Caution: Intragam P and Octagam have different concentrations of IVIG.

The medical order must specify:

the brand of IVIG to be given (Intragam P or Octagam) the dose in grams the volume in mls the rate of infusion

Description Intragam P Octagam

Presentation Solution, in vial sizes:

3g in 50mls 12g in 200mls

Solution, in vial sizes: 2.5g in 50mls 5g in 100mls

10g in 200mls

Concentration 60 mg per ml 50 mg per ml

Source Plasma Australian volunteer donors

Northern hemisphere remunerated

and volunteer donors

Plasma testing Hepatitis C, Hepatitis B, HIV, HTLV-I/II

Hepatitis C, Hepatitis B, HIV, ALT

Viral Safety 2 viral inactivation steps 2 viral inactivation steps

Key additives Maltose Maltose

Storage In hospital blood bank.

Refrigerated at 2-80C for up to 2 years.

In hospital blood bank. Stored below 250C for up to

2 years.

Compatibility May be flushed with sodium chloride 0.9% or glucose 5%.

May be flushed with sodium chloride 0.9% or glucose

5%.

IgA level < 0.4mg/g protein < or equal to 2mg/g protein

Administration

Do not use after expiry date. If the product is turbid by transmitted light or contains any sediment it must not be used. Allow it to reach room temperature prior to infusion. IVIG does not need to be mixed or diluted with any solution - it is given in pure concentrated form. It is not necessary to flush the line with saline between different batches. The IV line may be flushed through with 20mls of normal saline at the completion of the infusion to ensure the whole dose is administered.

Administration Rate

Intragam P

Start at 1ml/kg/hr (60mg/kg/hr) and increase at 30 min intervals up to 4ml/kg/hr (240mg/kg/hr), with a maximum rate of 240ml/hr.

Octagam

Start at 1ml/kg/hr (50mg/kg/hr) and increase at 30 min intervals up to 5ml/kg/hr (250mg/kg/hr), with a maximum rate of 250ml/hr.

The total dose of IVIG varies with the indication (for example the typical dose in Kawasaki disease is 2g/kg). In general, doses are rounded up so that all the vials opened are administered.

The maximum rates listed above should never be exceeded

Observations

Weight must be obtained on all patients prior to commencing IVIG therapy in order to correctly calculate the dose required.

TPR and Blood Pressure at:

baseline 30 minutes into infusion

Thereafter TPR every 30-60 min, depending on the condition of the patient.

All patients receiving blood products should be observed during the first 15 min of the infusion.

Long Term Replacement Therapy

Rate

Patients on long term IVIG replacement therapy for the management of a medical condition may commence infusion of IVIG at the maximum dose if this has been previously tolerated.

Intragam P maximum 240mls/hr Octagam maximum 250mls/hr

Observations

Weight at baseline to calculate the dose required

Patients on long term IVIG replacement require the following observations prior to the commencement of the infusion and at the completion of the transfusion.

TPR Blood Pressure

Ongoing observations during the infusion will depend upon the general condition of the patient but are not required as a routine as patients in the Day Medical Unit are under close nursing observation.

Reactions

Anaphylaxis is a rare but documented adverse effect of IVIG.

If anaphylaxis occurs STOP the infusion and give adrenaline 1:10,000 0.1ml/kg IM stat and oxygen

Anaphylaxis guideline

Other reactions tend to be related to the rate of infusion and are most likely to occur during the first hour of the infusion. If the rate is too fast, the patient may experience some of the following symptoms:

Dyspnoea Bronchospasm/Chest tightness Flushing Fever/Chills Hives/Rash Changes in BP Headache Vomiting/Nausea Abdominal pain Back pain/Arthralgia Severe coughing

At the first sign of any of these symptoms turn off the infusion and notify the doctor.

For mild reactions, when symptoms have ceased, the infusion may be recommenced at a slower rate.

Documentation

A record should be kept in the patient history of the following:

The date of the infusion Patient's observations and general condition during the infusion Amount given Product name, Batch Number and Expiry Date of each bottle used (place a sticker with batch

number on the drug or IV fluid chart if available)

This information is important should the patient have a reaction to the infusion, or if there is a need to trace recipients of certain batch numbers at a later date.

Intraosseous Access

See also: Resuscitation

Notes

Intraosseous (IO) access is an effective route for fluid resuscitation, drug delivery and laboratory evaluation that may be attained in all age groups and has an acceptable safety profile.

Indications:

IO access is the recommended technique for circulatory access in cardiac arrest. In decompensated shock IO access should be established if vascular access is not rapidly

achieved (if other attempts at venous access fail, or if they will take longer than ninety seconds to carry out.)

The exception is the newborn, where umbilical vein access continues to be the preferred route.

Contraindications:

Proximal ipsilateral fracture Ipsilateral vascular injury Osteogenesis imperfecta

Complications:

Failure to enter the bone marrow, with extravasation or subperiosteal infusion Through and through penetration of the bone Osteomyelitis (rare in short term use) Physeal plate injury Local infection, skin necrosis, pain, compartment syndrome, fat and bone microemboli have

all been reported but are rare

Equipment

Alcohol swabs 18G needle with trochar (at least 1.5 cm in length) 5 ml syringe 20 ml syringe Infusion fluid

Analgesia, Anaesthesia, Sedation

Local anaesthesia may be required if the patient is conscious.

Procedure

Identify the appropriate site Proximal tibia: Anteromedial surface, 2-3 cm below the tibial tuberosity Distal tibia: Proximal to the medial malleolus Distal femur: Midline, 2-3 cm above the external condyle

Prepare the skin Insert the needle through the skin, and then with a screwing motion perpendicularly / slightly

away from the physeal plate into the bone. There is a give as the marrow cavity is entered Remove the trocar and confirm position by aspirating bone marrow through a 5 ml syringe.

Send marrow blood for laboratory sampling (suitable for most standard laboratory values, pH, pCO2, HCO3-, and ABO and Rh typing.)

Marrow cannot always be aspirated but it should flush easily. Secure the needle and start the infusion (this needs to be manually administered as boluses

with the 20 ml syringe.)

Post-Procedure Care

Intraosseous infusion should be limited to emergency resuscitation of the child and discontinued as other venous access has been obtained.

Intussusception Guideline

See also: Abdominal Pain Guideline

Research study in progress - please click here

Intussusception is the invagination of a proximal segment of bowel into the distal bowel lumen. The commonest occurrence is a segment of ileum moving into the colon through the ileo-caecal valve. It may occur at any age but commonly occurs in the 2 month to 2 year age group with a peak incidence at 5 to 9 months.

Assessment

History

The child appears to have intermittent pain which is colicky, severe and may be associated with the child drawing up the legs.

Episodes typically occur 2-3 times/hour and may increase over the next 12-24 hours During these episodes of crying the child may look pale.

(note: many other causes of infant crying are associated with facial redness rather than pallor).

Pallor and lethargy may be the predominant presenting signs, may be persistent rather than episodic, and in some the crying episodes may not be very vigorous.

Vomiting is usually a prominent feature (but bile stained vomiting is a late sign) Bowel motions

blood and/or mucus classic red currant jelly stool is a late sign

diarrhoea is quite common and can lead to a misdiagnosis of gastroenteritis there may be a preceding respiratory or diarrhoeal illness

Examination

Pallor, lethargy - may be intermittent, and may look well in between episodes Abdominal mass - sausage shaped mass RUQ or crossing midline in epigastrium or behind

umbilicus, palpable in about two thirds of children. Distended abdomen later in the course Stool

Bloody stool/occult blood positive PR unnecessary if good evidence of intussusception; abdominal mass or PR

bleeding, but otherwise should be done for signs of PR blood or mass. Signs of an acute bowel obstruction Hypovolaemic shock is a late sign

Investigations

Plain abdominal Xray Performed to exclude perforation or bowel obstruction A normal AXR does not exclude intussusception Signs of intussusception on a plain Xray include:

1. Target sign - 2 concentric circular radiolucent lines usually in the right upper quadrant

2. Crescent sign – a crescent shaped lucency usually in the left upper quadrant with a soft tissue mass

Gas insufflation enema (or contrast enema) Diagnostic investigation of choice if high level of suspicion This intervention is both diagnostic and therapeutic

Ultrasound scan Useful if there is a suggestive history but no mass palpable or signs on plain AXR See flow chart

View flowchart

Blood tests Blood glucose Blood group and hold prior to theatre FBE and U&E’s may be useful if child looks unwell

Management

If shocked see resuscitation guidelines

Involve surgeons early

Secure IV access Most children will require fluid resuscitation with normal saline 20mls/kg IV Keep nil orally Pass nasogastric tube if bowel obstruction on AXR

Iron Poisoning

See also General Management of Acute Poisoning Guideline

Important ingestion is the amount of elemental iron not the iron salt

Patients Requiring Treatment

Ingestion of 20 mg/kg elemental iron. Ingestion of an unknown quantity. Any symptomatic patients

Assessment

Symptoms

Initial symptoms are usually: nausea, vomiting, haematemesis, diarrhoea

Fever is common Other Symptoms are related to fluid shifts from intravascular to extravascular compartments

and cellular hypoxia: tachycardia, vasoconstriction, hypotension, shock Metabolic Acidosis can occur

Beware the pale child

Investigations

Asymptomatic patients: If tablet ingestion do AXR, if clear and asymptomatic for 8 hours no tests are needed. If >60mg/kg ingested need serum iron levels (see below)

All symptomatic patients should have the following investigations: ABG/CBG Glucose

serum iron (serial levels every 4 hours) FBE U&E & Cr X-match and clotting profile performed.

AXR is helpful in evaluating gastrointestinal decontamination after treatment if tablets have been ingested.

Management

Charcoal is of no benefit. Decontamination of choice is whole bowel irrigation with colonic lavage solution

30ml/kg/hr until rectal effluent clear (only if bowel sounds present). Chelating agent available Desferrioxamine ( Desferrioxamine-iron complex usually turns

urine orange/red) . Supportive therapy to maintain adequate blood pressure and electrolyte balance is essential

a. Asymptomatic o If tablet ingestion do AXR, o If >60mg/kg ingested need serum iron levels 4 hourly until falling. o If AXR reveals tablets, or capsules ingested, whole bowel irrigation with colonic

lavage solution 30ml/kg/hr until rectal effluent clear. o Observe until 8 hrs post ingestion if asymptomatic discharge, if symptomatic treat as

below. b. Symptomatic

o whole bowel irrigation with colonic lavage solution 30ml/kg/hr until rectal effluent clear o Investigations as above. o I.V. fluid resuscitation, and potassium and glucose administration as necessary. o If altered conscious state, shock, severe acidosis (pH <7.1), or worsening symptoms

commence Desferrioxamine 15 mg/kg/hr I.V.

A Summary Of Patients Requiring Chelation Therapy

1. Any patient with symptoms of altered conscious state, hypotension, tachycardia or tachypnoea, or worsening symptoms irrespective of ingested dose or serum iron level.

2. Consider desferrioxamine in patients with symptoms who have serum iron levels > 60 micromol/l

All patients being considered for Desferrioxamine or with worsening symptoms must be referred to ICU (5212).

Jaundice in Early Infancy

Assessment

Investigation Of The Jaundiced Baby

View flowchart

Causes Of Neonatal Jaundice

Unconjugated

Breast milk jaundice - 3-5% of breast fed babies Prematurity - exaggerated physiological pattern; may last 4 weeks Bruising / cephalohaematoma – breakdown of heme Haemolysis (Rhesus, ABO, G6PD or PK deficiency, spherocytosis) - early onset for ABO,

Rhesus Sepsis - rarely presents with jaundice alone (occasional for UTI); usually unwell Metabolic (eg. hypothyroidism) - prolonged jaundice, can be mixed conjugated/unconjugated Polycythemia - delayed cord clamping, twin to twin transfusion Gilbert / Crigler-Najjar - rare, usually present as prolonged jaundice GI obstruction (eg. pyloric stenosis)

Conjugated - pale stools / dark urine, raised conjugated bilirubin (>25% total or >25umol/l)

Biliary atresia Choledochal cyst Neonatal hepatitis (congenital infection, alpha-1 antitrypsin deficiency; often idiopathic) Metabolic (galactosaemia, fructose intolerance - ask about sucrose/fructose in

food/medication) Complication of TPN

Notes

1. Physiological jaundice. Jaundice is very commonly noted in the first 2 weeks of life. It is part of a normal physiological process and affects 50 to 70% of babies. Mild jaundice with onset after 24 hours of life and which is fading by 14 days needs no investigation or treatment.

2. Breast milk jaundice is the most common cause of prolonged jaundice but other causes should be eliminated before making this diagnosis. A breast-fed baby with prolonged unconjugated jaundice, normal stool and urine colour, normal FBE/film/Coombs who is well and thriving probably has breast-milk jaundice. Do not stop breast feeding. Suggest review in General Paediatrics clinic if not improving or any changes - especially stool colour.

3. Conjugated hyperbilirubinaemia must be excluded as the causes of this pattern need urgent evaluation and treatment. Surgery for biliary atresia is most successful when the condition is diagnosed and treated early. Don’t forget to ask about the colour of urine and stools. View a dirty nappy yourself if possible.

4. Phototherapy or rarely exchange transfusion may be necessary in a baby with severe unconjugated jaundice associated with prematurity, haemolytic disease, or rare disorders such as Crigler-Najjar. Outside these conditions unconjugated jaundice is unlikely to lead to CNS or hearing problems, and no treatment is usually necessary.

Kawasaki Disease Guideline

Notes

Kawasaki disease is a systemic vasculitis that predominantly affects children < 5 years of age.

Although the specific aetiological agent remains unknown, it is believed that Kawasaki disease is a response to some form of infection (though it is not transmitted from person to person).

Diagnosis is often delayed because the features are similar to those of many viral exanthems.

The diagnostic criteria for Kawasaki disease are:

Fever for 5 days or more, plus

4 out of 5 of:

polymorphous rash bilateral (non purulent) conjunctival injection mucous membrane changes, e.g. reddened or dry cracked lips, strawberry tongue, diffuse

redness of oral or pharyngeal mucosa peripheral changes, e.g. erythema of the palms or soles, oedema of the hands or feet, and in

convalescence desquamation cervical lymphadenopathy (> 15 mm diameter, usually unilateral, single, non purulent and

painful)

and exclusion of diseases with a similar presentation: staphylococcal infection (e.g. scalded skin syndrome, toxic shock syndrome), streptococcal infection (e.g. scarlet fever, toxic shock-like syndrome not just isolation from throat), measles, other viral exanthems, Steven's Johnson syndrome, drug reaction and juvenile rheumatoid arthritis.

Click to view photos & description

The diagnostic features of Kawasaki disease can occur sequentially and may not all be present at the same time. Moreover, it is recognised that some patients with Kawasaki disease do not develop sufficient features to fulfill the formal diagnostic criteria. Clinical vigilance and recognition of this possibility are necessary to recognise these "incomplete" or "atypical" cases. This is important because the atypical cases are probably at similar risk of coronary complications and require treatment. Other relatively common features include arthritis, diarrhoea and vomiting, coryza and cough, uveitis, gall bladder hydrops. Some patients get myocarditis..

Investigations

All patients should have

ASOT / Anti DNAase B

Echocardiography (at least twice: at initial presentation and, if negative, again at 6 - 8 weeks). Platelet count (marked thrombocytosis common in second week of illness)

Other tests are not diagnostic or particularly useful. The following may be seen:

neutrophilia raised ESR + CRP mild normochromic, normocytic anaemia hypoalbuminaemia Elevated liver enzymes

Thrombocytosis and desquamation appear in the second week of the illness or later. Their absence earlier does not preclude the diagnosis.

Management

Patients require admission to hospital if Kawasaki Disease is diagnosed or strongly suspected.

Intravenous immunoglobulin (2 g/kg over 10 hours; preferably within the first 10 days of the illness but should also be given to patients diagnosed after 10 days of illness if there is evidence of ongoing inflammation - eg fever, raised ESR/CRP) Administration of Intragam Guideline

Aspirin 3 - 5 mg/kg once a day for at least 6 to 8 weeks. Some give a higher dose (10mg/kg 8 hourly for the first few days) but this probably adds nothing over immunoglobulin.

Provide the Kawasaki Disease Parent Information Sheet.

Parent Information Sheet (Print version - PDF)

Parent Information Sheet (HTML version)

Follow up

Paediatric follow-up should be arranged on discharge. At least one further echocardiogram should be performed at 6-8 weeks. If this is normal, no further examinations are needed.

Ketamine Use in the Emergency Department

See also: Nitrous Oxide Guideline Analgesia & Sedation Guideline

Notes

Ketamine is a potent sedative, amnestic, analgesic and anaesthetic agent. It has relatively little effect on the respiratory centre at the doses used.

The airway is to be managed by a doctor approved for this purpose by the Emergency Department.

Characteristics of Ketamine Dissociative State

Dissociation - the patient passes into a trance like state with the eyes open but not responding Catalepsy - normal or slightly increased muscle tone is maintained. Analgesia - excellent analgesia is typical Amnesia is usually total Airway reflexes are maintained. Cardiovascular state - Blood pressure and heart rate tend to increase slightly. Nystagmus is typical

Potential Side Effects:

Unpleasant emergence phenomena - more common beyond mid adolescence. Hypersalivation. Transient laryngospasm Transient apnea or respiratory depression Emesis Recovery agitation Random purposeless movements, muscle twitching and rash are common.

Patient Selection

Indications:

Children aged over 12 months - there is an increased risk of airway complications in children less than 12 months and particularly less than 3 months.

Short painful procedures especially those requiring immobilisation. Examples of these include: lacerations - especially of the face, and fracture reduction.

Contraindications:

Children under 12 months Food within four hours. Chest infection /URTI or lung disease including active asthma. History of previous airway surgery or congenital anomaly. Procedures that will stimulate the posterior pharynx. Cardiovascular disease including hypertension. Head injury with LOC, altered conscious state or vomiting. Poorly controlled seizure disorder. Glaucoma or acute globe injury. Psychosis, Porphyria. Thyroid disease.

Procedure

Staff required:

Airway doctor - must be approved by the Emergency Department Nurse

Doctor for the procedure.

Resuscitation equipment must be readily available.

Presedation

The procedure should be explained to the caregivers and child including an explanation of the effects of Ketamine.

Written informed consent must be obtained. Baseline observations should include BP, PR, RR and O2 saturation. Encourage the child and parents to talk (dream) about happy topics. This helps minimise

unpleasant emergence phenomena.

Adjunctive agents

Atropine 0.02mg/kg to a maximum of 0.6mg can be used to diminish hypersalivation. Midazolam 0.02 mg/kg may be added to ameliorate emergence phenomena in children over 5

years old.

These may all be mixed in the same syringe for intramuscular or intravenous injection.

Local anaesthetic agents may be used but are rarely required.

Administration:

IV: (with local anaesthetic cream)

Especially useful for procedures longer than 15-20 minutes The Ketamine dose of 1-1.5 mg/kg is given slowly over (1-2 min) as more rapid administration

is associated with respiratory depression. Further incremental doses of 0.5mg/kg may be given if sedation is inadequate or longer

sedation is necessary. Atropine and Midazolam may be given prior to or with the Ketamine.

IM:

Ketamine can be safely used without i.v. access. 3-4 mg/kg Ketamine with atropine and Midazolam mixed in the same syringe. A repeat dose of 2-4 mg/kg may be given after 10 minutes if sedation is inadequate.

Route of Administration

IM IV

Advantages No IV necessary Ease of repeat dosing, slightly faster

recovery

Clinical onset 5 minutes 1 minute

Effective sedation 15-30 minutes 10-20 minutes

Time to discharge (average)

100 -140 minutes 90-120 minutes

Monitoring

Each patient should have pulse oximetry and cardiac monitoring, and a nurse in attendance until recovery is well established.

Close observation of the airway and chest movements is necessary.

Post Procedure

Recovery

Nil orally until fully alert Nurse in a quiet area with minimal noise and physical contact, allow dim lighting if possible,

and do not stimulate prematurely. When patient is able to ambulate and verbalise at a level consistent with their pretreatment

functioning then they may be discharged home.

Discharge Instructions

Careful family observation and no independent ambulating for at least two hours.

Lacerations

Background

Minor lacerations are extremely common in childhood, and there are a variety of different methods of management available. It is important when active treatment is required that this is undertaken in a way which allows the best functional and cosmetic result, with the least distress to the child. The worst surgical results are achieved in children who are "uncooperative" or terrified. All children with lacerations should be fasted from arrival.

Assessment

Are there likely to be other injuries? (eg. head / cervical spine in falls, eye in facial trauma or teeth with mouth injuries).

Is the wound likely to be contaminated by dirt or foreign bodies? Is there injury to deeper structures (eg. tendons, nerves)? In the face, remember facial nerve,

parotid / lacrimal ducts, medial canthus of the eye. If a deep laceration cannot be examined adequately to exclude damage to such structures, general anaesthesia may be required.

Is blood supply impaired? If a flap or area of soft tissue distal to the laceration appears dusky or poorly perfused, the wound requires specialist assessment. Areas with end-arteriolar supply (extremities such as the tip of the nose, finger tips, and ear lobes) require special care. Do not use local anaesthesia with adrenaline on such wounds.

Management

Before embarking on treatment in a child, consider whether you have the necessary resources for optimum surgical result and experience for the child eg. sedation, analgesia, anaesthesia, appropriate experience, time & instruments, assistance (medical and nursing). If in any doubt discuss with Emergency Registrar or Consultant. Plastic surgical consultation may be advisable.

Sedation

See Sedation Guideline

Anaesthesia

See Sedation Guideline

Adequate anaesthesia is necessary for complete examination, cleansing and repair of wounds.

1. Topical anaesthesia o ALA (adrenaline/lignocaine/amethocaine) 0.1 ml/kg. o EMLA or AnGel applied to the wound (most effective on limb wounds)

2. Local anaesthesia o eg. 1% lignocaine with adrenaline slowly infiltrated into the wound, (care should be

taken not to use adrenaline on finger tips) 3. Regional block

o eg. infiltrate nerve proximal to injury (ring block digits - use plain lignocaine, no adrenaline) Nitrous oxide may facilitate a more comfortable injection.

4. Bier's Block (i.v.) o To be done by doctor of appropriate training only - see Bier's Block guideline.

Cleaning Wounds

Superficial Wounds

Can be cleansed with saline or aqueous chlorhexidine.

Deep Wounds

Those which require exploration should be anaesthetised first to allow more thorough cleaning. Foreign bodies must be removed. Grease can be removed using Bacitracin or Polysporin ointment.

Thorough irrigation with saline under pressure (with a 19 Ga needle on a 10-20 ml syringe) is advisable

Gravel Rash

Bitumen and dirt is ground into the skin and there is associated skin abrasion. After anaesthesia, scrub with a brush to remove ground in dirt and prevent tattooing. Small area - local anaesthetic. Larger areas - general anaesthetic.

Ragged Wounds

Trim edges of wound where the viability is in doubt.

Glass Injuries

These should be x-rayed if there is the possibility of retained glass. If glass fragments are present, the wound needs exploration. All haematomas should be evacuated as glass is usually found within.

Closure

a) Non-surgical

Dressing only (see wound dressing guideline) Simple lacerations (small, superficial wounds which are not gaping or contaminated)

can be managed with dressings alone. Puncture wounds are usually best left open although they may require exploration or

debridement if deep or contaminated.

Tissue adhesive ("Dermabond glue") Can be used on wounds which have clean edges, do not require deep sutures and

are not under tension. Best for wounds of less than 3cm in length with edges easily held together. Do not use on mucosal surfaces. If glueing the forehead or in the vicinity of the eye, the eye should be padded to avoid

any glue dripping into the eye or onto the eyelashes. Oppose the edges of the wound and apply very small amount of glue to the surface,

holding the edges together for 30 secs. Do not allow glue to enter wound itself (non-absorbable - acts as foreign body).

Generates heat (may be uncomfortable if applied too thickly). Care should be taken not to apply too much tissue glue and to avoid placement over

currently bleeding wounds as the polymerisation is exothermic and the patient will notice a heat sensation. The tensile strength of the bond will be reduced also.

Does not require removal; comes off in 1-2 weeks.

Adhesive strips ("Steristrips") May be adequate in simple lacerations which require opposition of slightly separated

wound edges. They do not remain in place for long periods, and should not be used if there is

movement or tension across the wound. Prepare skin with tincture of benzoic compound to aid adhesion. Place strips with sufficient space between each to allow drainage of fluid from the

wound to avoid infection. Keep dry for 72 hours.

b) Surgical

NB: Young or anxious children will require sedation prior to wound repair See sedation guideline

Scalp Bleeding may be profuse, but usually ceases with firm digital pressure along the

margins of wound. Comb hair out of wound (vaseline often helps). It is not usually necessary to shave much hair.

Close in 2 layers: GALEA 3/0-5/0 Chromic Cat Gut (CCG) or PDS (absorbable) SCALP 4/0-5/0 Nylon (Removal of sutures [ROS] ~7 days)

Forehead

Minimal debridement. Do not shave eyebrow Superficial scratches should be cleaned only and left to epithelialise (± steristrips) Sutures 5/0, 6/0 Nylon (ROS 5-7 days) or Fast gut or Vicryl absorbable sutures

Cheek

Check for fractures (zygoma, blow out of orbit) and involvement of facial nerve and muscle.

Ophthalmology opinion if hyphaema or "closed eye with swelling". Close as for forehead

Eyelids

If involving the lid margin then refer to Ophthalmology. Look for tarsal plate involvement - refer Ophthalmology Simple lacerations can be glued or sutured under low tension. Use 6/0 Vicryl or Fast

Gut absorbable sutures.

Lips Superficial lacerations can be closed in Emergency by person with appropriate

experience if the child is cooperative. Otherwise will need GA and Plastic surgical repair.

NB: Need accurate approximation of vermilion border and skin. Sutures: skin - 6/0 Nylon (ROS 5 days) or Fast Gut (absorbable); mucosa and muscle - 4/0 CCG, Vicryl

Lacerations of the inner lip rarely need any intervention. Lacerations of the gum margin (e.g. degloving injury) need referral to Dental or Facio-

Maxillary.

Limbs Immobilise area of laceration and joint above and below, following repair eg. plaster

slab or sling. Upper Limbs: May require arterial tourniquet control. 4/0, 5/0 Nylon. Deep sutures

4/0 PDS. Lower Limbs: Debridement important. Do not close if under undue tension especially

pretibial, ROS 7-10 days.

Trunk

Debridement can be more generous. Fat layer: 3/0 PDS. Skin: 4/0, 5/0 Nylon. ROS 10-14 days.

Digits & Hand Subungual Haematoma:

Usually caused by blunt trauma to the finger tip. If < 50% of nail bed - treat with ice and analgesia only If > 50% and significant pain - then burn hole in nail to relieve the pressure

Small lacerations of finger tips with skin loss are very common. Areas of skin loss up to 1 cm2 are treated with dressings and heal with good

return of sensation. Any greater degree of tissue loss should be referred for plastic surgical opinion.

Partial-amputation / crush injury. Need to assess the integrity of the nail bed - if damaged needs plastic

surgery repair. X-ray to look for fracture of distal phalynx. A fracture implies damage to the nail bed. Discuss management with Plastics.

Palm: Be careful in assessing wound especially in very young children as deeper

structures (eg nerves and tendons) may be involved. If in doubt consult Plastics.

Compound injuries (i.e. fracture and laceration) should have antibiotic cover.

Palate Beware: sharp objects in the mouth may injure the posterior pharynx. Consult with

senior staff. These rarely require suturing unless gaping widely, extending through posterior free

margin or continuing to bleed.

Tongue Most lacerations do not require suturing. However, if the laceration is large, extending

through the free edge, full thickness or associated with ongoing bleeding, Plastics opinion is necessary.

Ear

If full thickness involving cartilage, needs Plastic opinion.

Tetanus Prophylaxis

See Management of tetanus-prone wounds

Antibiotics

Antibiotics are not indicated for simple lacerations. They are usually given for bites and wounds with extensive tissue damage, or massive contamination, but are secondary in importance to the initial decontamination of the wound. Recommended antibiotics are procaine penicillin 25-50 mg/kg i.m. once and augmentin (10-20 mg amoxycillin/kg) 8-hourly for 5 days.

Local Anaesthetic, Manipulation and Plaster (LAMP)

Doctors must discuss previous experience and training in this procedure with the Director of the Emergency Department before proceeding, and should be fully familiar with the equipment used.

Indication

Children over 5 yrs with forearm fractures requiring manipulation - some younger children if very cooperative. Distressed or non-compliant children may be better treated Under GA.

Preparation

Prior to X-Ray

Give adequate pain relief Painstop 1.0mL/kg or Pethidine 1.0-1.5mg/kg IM or Morphine 0.1-0.2 mg/kg IM

Keep child nil orally. Put EMLA/amethocaine on both hands.

Once decision is made to proceed to LAMP

All LAMP procedures are to be ED admissions. A yellow form should be taken to the ward clerks to be processed. Informed consent must be obtained from parents.

Procedure must be performed in Proceedure Room with full resuscitation equipment. Check all Equipment.

Notify radiology to ensure availability of staff prior to commencing.

Procedure

Two doctors must be present. Apply a tourniquet to the affected arm. Insert an i.v. cannula (not a butterfly) into a distal vein of both arms Elevate the arm above the level of the child’s heart for 1 minute with compression of the

brachial artery.

Inflate the tourniquet cuff to 200 mmHg. This reading is maintained throughout the procedure and remains the responsibility of the second attending doctor.

Infuse Lignocaine 0.5% 0.6mls/kg (3 mg/kg); max dose 40ml. Commence manipulation only after full anaesthesia has been obtained (usually.takes 5-10

minutes). Note: Nitrous oxide or intravenous opiate may be useful as an adjunct in some children.

Apply plaster to the forearm (below elbow). Arrange portable post-reduction film in ED. If possible wait until the X-ray is available to

assess the position post-manipulation before releasing the tourniquet. Release the tourniquet cuff.

Note: Not to be released before 20 minutes after lignocaine infusion. Complete the plaster cast (above elbow).

After the Procedure

The child may be discharged from the ED after the cuff is released. Arrange plaster check LMO on the following day. Organise Fracture Clinic and X-ray appointment at 5-7 days. Complete yellow Discharge Summary and operative notes on Surgical Short Stay form.

Lumbar Puncture Guideline

See also: Meningitis CSF Interpretation LP Parent Handout References for LP Guideline

Notes Indications, Contraindications, Complications

Equipment Analgesia, anaesthesia and sedation Procedure Post-procedure care

Notes

Lumbar puncture may be performed as part of the initial work up of a sick child, or later in the course of an illness once the child has stabilised if there were initial contraindications. It is preferable to obtain a CSF specimen prior to antibiotic administration, however this should not be unduly delayed in a child with signs of meningitis or sepsis.

You must always discuss with a senior registrar or consultant before doing a lumbar puncture.

Indications:

Suspected meningitis or encephalitis See Meningitis, febrile convulsion, fever

Suspected Sub-arachnoid haemorrhage with a normal CT

Contraindications:

You must always discuss with a senior registrar or consultant before doing a lumbar puncture. Do not do a lumbar puncture if the child is so sick that you will give antibiotics for meningitis even if the CSF is normal is normal on microscopy.

The clinical findings that suggest you should give dexamethasone and antibiotics immediately, and delay lumbar puncture for 1-2 days until the child is improving are ...

Coma: absent or non-purposeful response to painful stimulus - squeeze ear-lobe hard for up to one minute. A child over 3 months of age should push you away and seek a parent.

Signs of raised intracranial pressure. Eg abnormal pupillary responses, unilateral or bilateral motor posturing or papilloedema (NB papilloedema is an unreliable and late sign of raised ICP in meningitis; a bulging fontanelle in the absence of other signs of

raised ICP, is not a contraindication). Cardiovascular compromise / shock Respiratory compromise Focal neurological signs or seizures Recent seizures (within 30 minutes). Coagulopathy/thrombocytopenia Local infection (in the area where an LP would be performed) The febrile child with purpura where meningococcal infection is suspected.

Assessment prior to LP for contraindications?

CT Scans if focal neurological signs CT Scans are not helpful in most children with meningitis. A normal CT scan does not tell you that the patient does not have raised ICP. Herniation may occur even in the presence of a normal scan. See flow diagram Lumbar puncture, imaging and antibiotics

Complications:

Informed verbal consent should be obtained. This should include a discussion of the benefits of the procedure in terms of possible diagnoses and potential complications. Complications of LP may include:

Failure to obtain a specimen / need to repeat LP/ Traumatic tap (common) Post-dural puncture headache (fairly common) - up to 5-15% Transient/persistent paresthesiae/numbness (very uncommon) Respiratory arrest from positioning (rare) Spinal haematoma or abscess (very rare) Tonsillar herniation (extremely rare in the absence of contraindications above)

The LP Parent Information Sheet may be useful in talking to parents about the procedure. (See below)

Analgesia, anaesthesia and sedation

Non-pharmacological techniques should be used where possible, including explanation (in an older child), distraction, and the presence of a parent.

All children should have some form of local anaesthetic for lumbar puncture. Use topical anaesthetic cream (AnGEL) except where specimens are required

urgently Subcutaneous lignocaine may be used in addition to or instead of topical anaesthetic.

Use up to 0.4ml/kg of 1% (4mg/kg) Oral Sucrose should be used for infants <3 months (see <a

href="/clinicalguide/cpg.cfm?doc_id=5144"/>Analgesia guideline) Sedation, including nitrous, should be considered for children older than 6 months with normal

conscious state

Monitoring:

Monitor all sedated or seriously ill children with continuous pulse oximetry

Equipment

At least one trained assistant to hold the child Sterile gloves Sterile drapes and procedure tray Skin preparation: povidone iodine solution (Betadine) or chlorhexidine Local anaesthetic lignocaine, 2ml syringe, 25G needle CSF tubes (2) Spinal needle (see below) NB Spinal manometry is not routinely performed in children during lumbar puncture.

Spinal Needles

22G bevelled spinal needles with stylet (the use of needles without a stylet has an associated risk of spinal epidermoid tumours)

see Spinal needles for a guide to needle size and insertion distance Consider 25G pencil point needles for older children/adolescents (eg Whitacre 25G 9cm

available in ED at RCH) Pencil-point (blunt) needles reduce the risk of headache in adults, however the

evidence is not convincing in children. Their use may be appropriate in adolescents.

Procedure

The most important determinant of a successful lumbar puncture is a strong, calm, experienced assistant to hold the patient. Position of the patient is critical.

Position:

Lumbar puncture may be performed with the child lying on their side or sitting up. Aim for maximum flexion of the spine (curl into fetal position), but avoid over flexing the neck,

especially in infants as this may cause respiratory compromise. Ask an adolescent to slouch rather than bend from their hips.

Ensure that the plane of the back is exactly at 90 degrees to the bed (ie not leaning towards or away from you). Make sure the hips and shoulders are in line

Draw an imaginary line between the top of the iliac crests. This intersects the spine at approximately the L3-4 interspace (mark this if necessary)

The conus medullaris finishes near L3 at birth, but at L1-2 by adulthood Aim for the L3-4 or L4-5 interspace

Preparation:

Wash hands and aseptically put on sterile gloves Prepare the skin with povidone-iodine or chlorhexidine and set up sterile drapes. Allow adequate time for the skin preparation to dry Take the tops off the tubes, ensuring that they remain sterile. Infiltrate the skin with 1% lignocaine using a 25G needle

Lumbar Puncture:

Position the needle in the midline with the bevel pointing towards the ceiling (lateral decubitus position) or to the side (sitting).

Pierce the skin with the needle and pause. Wait for the child to stop wriggling Reorientate (ensure that back is vertical, needle is parallel to the bed and perpendicular to the

back). Aim for the umbilicus (ie slightly cephalad). Advance the needle into the spinous ligament (increased resistance). Continue to advance

the needle within the ligament until there is a fall in resistance. Remove the stylet. If CSF is not obtained replace the stylet and advance the needle slightly then recheck for CSF.

An alternative technique is to remove the stylet once the needle is in the ligament and advance very slowly without stylet watching for CSF to flow back. This has the advantage of making it harder to go unintentionally past the subarachnoid space.

If the needle meets resistance, withdraw the needle slowly whilst watching for CSF. If none is obtained, replace the stylet, re-orient the needle and re-try.

If blood stained fluid is obtained collect some for culture. If it clears it can be used for a cell count. If it fails to clear another attempt at a different level may be required.

See Spinal needles for a guide to insertion distance If CSF is flowing, collect into 2 numbered sterile tubes (5-10 drops each is usually adequate) Replace the stylet (this may reduce risk of headache), and remove the needle and stylet. Apply brief pressure to the puncture site Send specimens urgently to the lab for microscopy, protein, glucose, culture. (NB CSF

glucose estimation is most useful if there is a synchronous plasma glucose). see CSF Interpretation

Post-Procedure Care

Cover the puncture site with a band-aid or occlusive dressing (eg Tegaderm) Bed-rest following lumbar puncture is of no benefit in preventing headache in children or adults.

Lumbar puncture

A lumbar puncture is a test where a doctor uses a needle to get fluid out from the back. (This fluid is called "spinal fluid" or "CSF"). Your child lies on his or her side and is held still. A doctor puts a needle between the bones of the lower back. It does not go near the spinal cord. Lumbar Punctures are also sometimes called a "spinal tap" or "LP".

Why does my child need a lumbar puncture?

This test is usually done to find out if your child has infection of the fluid around the brain (meningitis). It is the only way to know for sure if your child has meningitis or not. If your child has meningitis they will need other tests and treatment in hospital. Occasionally lumbar punctures are done for other reasons.

What happens during a lumbar puncture?

Does it hurt?

It is an uncomfortable and sometimes painful test. Your child will be held still, and babies and small children do not like this and often cry. We can help to numb the skin with some cream or with an injection. We may be able to give your child some medicine to make them less scared and worried.

What are the risks?

Lumbar puncture is a very safe test. Sometimes we are not able to get fluid and may have to try more than once. A small number of children may have a headache or backache for a day or two after the test. The risk of any serious complications (bleeding or infection, damage to nerves) is extremely small.

Do I need to do anything special after the lumbar puncture?

Your child can be bathed normally. If there is a band-aid or dressing on your child's back it can be taken off the next day. If they have a headache or sore back they can have some paracetamol (Panadol).

Key points to remember about having a lumbar puncture

Lumbar punctures are the only way to be sure if your child has meningitis or not. It is a very safe test.

MET Criteria - Call 777 for help

Read more about the RCH Medical Emergency Team (MET) here

Staff Member or parent worried about patient's clinical state

Airway threat

Hypoxaemia:

SpO2 <90% in any amount of oxygen SpO2 <60% in any amount of oxygen (cyanotic heart disease)

Severe respiratory distress, apnoea or cyanosis

Tachypnoea

Age Respiratory rate Term-3 months >60

4-12 months >50 1-4 years >40

5-12 years >30 12 years+ >30

Tachycardia or bradycardia:

Age Heart rate too Heart rate too

slow fast Term-3 months <100 >180

4-12 months <100 >180 1-4 years <90 >160

5-12 years <80 >140 12 years+ <60 >130

Hypotension:

Age BP (systolic) Term-3 months <50

4-12 months <60 1-4 years <70

5-12 years <80 12 years+ <90

Acute change in neurological status or convulsion

Cardiac or respiratory arrest

Notes

Some of the values for respiratory rate, heart rate and blood pressure are outside the normal

ranges for age: they represent concerning levels that may indicate serious illness, and that require

expert review.

It is also important to look for worsening trends in vital signs and report these.

Meningitis Guideline

See also: Fluids in Meningitis guideline Use of Vancomycin in meningitis Lumbar Puncture Guideline CSF Interpretation

Meningococcal infection Coma Convulsions in children with meningitis Febrile Child under 3 years

Background Assessment Management

Therapy summary Antibiotics Steroids Admission to ICU General Measures Notification Contact chemoprohpylaxis

Notes Follow-up Viral Meningitis

Background

The usual organisms causing bacterial meningitis in children over 2 months of age are

Streptococcus pneumoniae, Neisseria meningitidis Haemophilus influenzae type b (Hib ﾷ uncommon after age 6).

Organisms to consider in infants under 2 months of age include

Group B streptococcus, E. coli and other Gram-negative organisms, Listeria monocytogenes, S. pneumoniae, N. meningitidis Haemophilus influenzae type b.

Note: This guideline is not for use in children with spinal abnormalities or ventriculo-peritoneal shunts etc. where the neurosurgical team should be consulted

Assessment

Infants with meningitis frequently present with non-specific signs and symptoms such as fever, irritability, lethargy, poor feeding and vomiting.

The fontanelle may be full. Older children may complain of headache or photophobia. Neck stiffness may be present (not a reliable sign in young children). A purpuric rash is suggestive of meningococcal septicaemia.

It is important to examine for spinal and cranial abnormalities such as dermal sinuses which may have predisposed the child to meningitis.

Investigations

You must always discuss with a senior registrar or consultant before doing a lumbar puncture.

Lumbar puncture (LP) see Lumbar Puncture guideline, CSF Interpretation guideline

Blood tests Full blood count/differential Glucose, urea and electrolytes Blood cultures

Management

Therapy (summary)

Age Antibiotics Steroids If Strep. Pneumoniae suspected

>2 months Cefotaxime 50 mg/kg (2 g) iv 6H

Dexamethasone 0.15 mg/kg, iv 6H

add Vancomycin 15 mg/kg (500 mg) iv 6H

4 weeks-2 months

Cefotaxime 50 mg/kg (2 g) iv 6H, Benzylpenicillin 60 mg/kg iv 4H and Gentamicin

Dexamethasone 0.15 mg/kg, iv 6H Substitute Vancomycin

15 mg/kg (500 mg) iv 6H for Penicillin

<4 weeks</strong/>

Cefotaxime 50 mg/kg (2 g) iv 6H, Benzylpenicillin 60 mg/kg iv 12H (wk 1 of life) 6-8H (wk 2-4 of life), Gentamicin

No

Substitute Vancomycin 15 mg/kg (500 mg) iv 6H for Penicillin

Antibiotics

Cefotaxime can be substituted with Ceftriaxone 100 mg/kg (max 2gm) iv daily Chloramphenicol may be used in children with a type 1 hypersensitivity to cephalosporins. Continue empiric treatment until cultures are known to be negative or an organism and its

sensitivity pattern are known. A positive culture result with sensitivities should lead to narrower spectrum treatment:

Organism Antibiotics

N. meningitidis Benzylpenicillin 50mg/kg/dose (max 3g), iv 4 hourly for 7 days (Penicillin-sensitive)

S. pneumoniae Benzylpenicillin 50mg/kg/dose (max 3g), iv 4 hourly for minimum of 10 days (Penicillin-sensitive)

Haemophilus influenzae type b

Cefotaxime 50mg/kg/dose (max 3g), iv 6 hourly for 7-10 days

Other If an organism is not isolated, but significant CSF pleocytosis is present, a minimum of 7 days treatment with intravenous cefotaxime is recommended.

Prolonged therapy will be required for neonatal and Gram-negative bacillary meningitis.

Steroids

Current evidence suggests that steroids protect against neurological sequelae from bacterial meningitis (particularly deafness) and may reduce mortality.

The benefit is probably greatest if steroids are given at least 15 minutes before the first dose of antibiotics.

Accordingly, children (>4 weeks old) who are being treated for possible meningitis (who have not yet received parenteral antibiotics, or who have received their first dose less than 1 hour ago) should be given dexamethasone.

Give Dexamethasone 0.15mg/kg iv 6 hourly for 4 days Wait 15 minutes before giving antibiotics after the first dose. Antibiotics must not be delayed more than 30 minutes after a decision is made to treat.

Steroids should be ceased if a decision is made to cease antibiotic treatment for meningitis before 4 days (eg if cultures are negative at 48 hours, and CSF microscopy not supportive).

From a practical point of view, it may be appropriate to give dexamethasone at the time of lumbar puncture in children who are felt to be very likely to have meningitis.

Convulsions in children with meningitis

Convulsions should be treated quickly in a child with suspected / confirmed meningitis. An already compromised brain may be further damaged by the metabolic demands of a fitting brain and compromised breathing and circulation during the convulsion

Give oxygen 6-8 litres by face mask. Nurse on the side. Suction to clear the oropharynx, and place an oral airway as necessary. If the child is apnoeic use bag and mask ventilation and immediately call ICU.

Do a blood glucose stick test. Treat hypoglycaemia (<3 mmol/L) with 2 ml/kg of 25% glucose iv as a slow bolus.</p/>

If convulsion continues for 2 minutes, give diazepam 0.2 mg/kg iv over 30 seconds, or 0.4 mg/kg pr. If continues after further 5 minutes, repeat diazepam 0.4 mg/kg iv over 30 seconds and notify ICU and the Medical Consultant.

Check laboratory blood glucose, acid base and electrolytes.

If the convulsion ceases after diazepam, load with phenytoin (15 mg/kg iv over one hour).

Do a neurological examination: if focal deficit, very bulging fontanelle or poor conscious state notify ICU and organise a CT scan.

Monitor conscious state, oxygen saturation, blood pressure and continuous ECG.

Admission to ICU

Admission to ICU should be discussed with the ICU consultant in the following circumstances:

age less than 2 years coma cardiovascular compromise intractable seizures hyponatraemia

Fluid Management

see Fluids in Meningitis Guideline

General measures

Neurological observations including blood pressure should be performed 15 minutely for the first two hours and then at intervals determined by the childﾷs conscious state.

Weight and head circumference should be monitored on a daily basis. Control seizures Early consultation with intensive care unit is necessary for any child who is

experiencing a deterioration in conscious state, haemodynamic instability or seizures. Electrolytes and glucose should be checked 6-12 hourly until the serum sodium is normal

(and/or the child is no longer on IV fluids). Ensure adequate analgesia (eg paracetamol) for children in the recovery phase who may

have significant headache. Fever persisting for more than 7 days This may be due to nosocomial infection, subdural

effusion or other foci of suppuration. Uncommon causes include inadequately treated meningitis, a parameningeal focus or drugs.

Notification

All cases of presumed or confirmed Neisseria meningitidis disease should be urgently notified to the Department of Human Services by telephone on 1300 651160 (fax 1300 651170) (after hours pager 03 9625 5000, pager number 46870).

Haemophilus influenzae type b, and streptococcus pneumoniae are also notifiable diseases. Link to DHS info on meningococcus Link to DHS notifications (include form)

Contact Chemoprophylaxis

see Contact Chemoprophylaxis Table

It is important that prophylaxis be given early to both the index case and contacts.

Rifampicin may cause orange-red discolouration of tears, urine and contact lenses, skin rashes and itching, and gastrointestinal disturbance. It negates the effect of the oral contraceptive pill and should not be used in pregnancy or severe liver disease.

At RCH, a supply of rifampicin capsules and syrup is kept in the ICU pharmacy cupboard (bottom shelf right hand side). Immediate families members may be given free supplies (click here for info).

There is a Parent Information Sheet which gives details of meningococcal infection and the use of rifampicin.

Notes

Follow-up

All children with bacterial meningitis should have a formal audiology assessment 6-8 weeks after discharge (earlier if there are concerns regarding hearing).

Neurodevelopmental progress should be monitored in outpatients.

Viral Meningitis

CSF findings may be suggestive (see CSF interpretation guideline). Admission is required if the diagnosis is in doubt and/or antibiotics or intravenous hydration

are required. Ensure adequate analgesia Parent Information Sheet (Print version - PDF)

Meningococcal infection

Meningococcal infection is caused by a bacteria germ called meningococcus. Meningococcus can cause serious infections including:

Meningitis, an infection of the covering of the brain and spinal cord. Septicaemia, serious infections of the blood. Infections in other parts of the body (such as in the joints).

These infections can develop very quickly, and are deadly in about 1 in 10 cases. For others, the infection can cause disabilities that affect them for life. Many people carry the bacteria in their noses and throats without getting sick. We call them healthy carriers. These carriers can spread the bacteria to other people. The meningococcus is spread by tiny drops of fluid from the nose and throat through coughing, sneezing and spluttering, sharing eating and drinking utensils. It is not easy to get infected because the bacteria do not live long outside the body.

Signs and symptoms

Your child may only have some of these symptoms, or may not have them all at once.

Children and adults

High fever Severe headache Stiffness and pain in the neck, shoulders, back, and other muscles Skin rash of small bright red spots or purple bruises Dislike of bright lights (photophobia) Lethargic, drowsy or confused Nausea and vomiting (feel sick)

Babies

Fever High pitched moaning cry Fretful or agitated Refusing feeds or vomiting Being difficult to wake Pale or blotchy skin Rash of red-purple spots or bruises

In newborns and babies, the typical symptoms may be hard to detect.

Symptoms will show up within 2-10 days (usually 3-4 days) after your child has been in contact with meningococcus. Symptoms often begin suddenly.

Anyone showing signs of meningococcal infection needs to see a doctor immediately.

Treatment

If your child has symptoms of meningococcus they will be treated in hospital with antibiotics. Early treatment with antibiotics is the key to saving their life. Diagnosis is not always easy to make in the beginning. If your child is sent home by the

doctor or hospital and becomes worse or doesn’t improve, take them straight back to the nearest hospital.

Treatment for contact people

If your child has been in contact with a person who has meningococcus they may need antibiotic treatment. Contacts may include:

Somebody who lives in the same house and shares meals and living space. A person who has contact with your child's mouth or nose secretions. This can happen by

using the same eating and drinking utensils, glasses, and plates or through kissing (remember boyfriends/girlfriends) or by sharing cigarettes.

A person who has done medical treatments like giving mouth-to-mouth resuscitation on your child.

Children sharing toys, such as in group day care centres, family day care, or in nurseries.

By law, doctors treating patients with suspected or confirmed meningococcal disease must notify the Department of Human Services (The Health Department). They will probably contact you for more information. Your doctor and the Department of Human Services will let you know who should have antibiotic treatment.

Antibiotics - Rifampicin

Rifampicin is the antibiotic medicine that is most often used to get rid of the meningococcus germ from the throat of contacts. This will prevent it being passed on to other people. Usually two doses are given each day for two days.

Any contacts who need to take antibiotics must tell their doctor if they:

Take medicine for epilepsy. Take medicine for blood thinning. May be pregnant or are breastfeeding. Have a history of liver or kidney disease. Have had a reaction to rifampicin in the past.

These people should not take rifampicin. There are other medicines they can take.

Side effects of rifampicin

Body secretions such as, urine, stool (poo), saliva, sputum (spit), sweat, and tears, may turn red or orange in color. This is only temporary.

Stomach aches, vomiting, diarrhea, headaches, dizziness, or pain in the arms and legs. These symptoms will go away after the medicine is finished.

Soft contact lenses may be permanently stained red or orange. They should not be worn until 48 hours after finishing the medicine.

Birth control pills may not work properly when taking rifampicin.

Follow instructions for taking rifampicin carefully.

Taking rifampicin does not guarantee prevention of the illness. Therefore, if any of the above symptoms for meningococcal infection develop, that person must seek urgent medical attention.

Prevention of meningococcal infection

Have your child vaccinated against meningococcal C disease. The vaccine provides over 90% protection against meningococcal C disease. Please discuss all side effects with your doctor.

Children of parents who smoke are at a greater risk of getting meningococcal disease. For help to quit smoking, call the Quitline on 131 848.

Key points to remember

These infections can develop very quickly, and can be deadly in about 1 in 10 people. Others are affected for life.

If your child has been in contact with a person who has meningococcus they may need antibiotic treatment.

Symptoms will show up within 2-10 days (usually 3-4 days) after your child has been in contact with meningococcus.

If your child is sent home by the doctor or hospital and becomes worse or doesn’t improve, take them straight back to the nearest hospital.

Acute Meningococcal Disease

See also: Fever and petechiae/purpura guideline Meningitis guideline

Notes

IV antibiotics should be given as soon as possible whenever meningococcal disease is suspected (im, or intraosseus, if iv access can not be obtained). Blood cultures should preferably be taken before the antibiotics are given. If this will lead to a delay of more than 5 minutes, then give antibiotics immediately.

Cefotaxime or ceftriaxone are the first choice antibiotics (at RCH use cefotaxime). If unavailable, use benzyl penicillin.

Other bacteriological investigations (see below) can be useful if collected early but should not delay antibiotic therapy.

Emergency Drug & Fluid Calculator

Clinical presentation

Common presentations

meningitis (see also meningitis guideline). meningococcaemia (classically as fever + purpura but can be non-specific septic

presentation)

Meningitis and meningococcaemia commonly occur together.

Examples of rash. Click her to see full size

Less common presentations

arthritis pneumonia pharyngitis occult bacteraemia.

Features of acute meningococcaemia

The usual presentation is with any of fever, malaise, myalgia, arthralgia, nausea, vomiting, headache, and reduced conscious state. In infants, fever and listlessness or prostration may be the main features.

Petechiae or purpura are present in most, but not all, patients.

Any child with meningococcal disease, including one who appears non-toxic, may deteriorate rapidly.

Management

All patients should be admitted to hospital under General Medicine.

Consult ICU for all cases of acute meningococcaemia, and those with meningitis <2years of age.

Isolate cases (if possible) until they have had >12 hours antibiotic treatment.

Antibiotics

Gain intravenous access (or intraosseous access if iv not possible).

Take blood (or marrow) for culture if possible and immediately administer cefotaxime (50mg/kg/dose - max 3g, 6 hourly). Chloramphenicol may be used in children with a type 1 hypersensitivity to cephalosporins.

When meningococcal infection is confirmed (including sensitivities), this may be changed to iv benzylpenicillin 50mg/kg/dose – max 3g, 4 hourly for 7 days.

Fluids

Meningococcaemia is often associated with hypovolaemia, give 20 ml/kg of normal saline. More fluid will often be needed to improve blood pressure and peripheral perfusion (40 ml/kg or more in the first hour is common).

For meningitis alone, careful fluid management is important as many children have increased ADH secretion. See meningitis guideline.

ICU management

Consider intubation early.

Give methylprednisolone (10mg/kg) before (or within 30 minutes) first dose of antibiotics.

Consider hydrocortisone 1mg/kg 6 hourly - especially if on inotropes.

Consider immunoglobulin 0.5g/kg over 2 hours.

Investigations

Microbiological

If possible blood culture should be obtained prior to, or very soon after, commencing antibiotics.

The other investigations should be obtained within the following hour if possible.

Blood curlture if no BC bottles available, a plain sterile "clotted" tube may be used

Blood smear Smear 1 drop onto a microscope slide for Gram stain

2-5 mls of blood in EDTA tube

This will be used for meningococcal PCR

Throat swab In transport medium

Lumbar puncture Contraindicated in the initial management of the child with fever & purpura Appropriate in suspected meningitis (without purpura) when no other contraindications exist .

Other as appropriate eg joint aspirate for culture and PCR

Some of these investigations will guide your patient's management, the rest will help with public health and contact management. Please ensure all specimens are transported to RCH with the patient if possible. Meningococcus is sensitive to cold - ensure cultures are transported to laboratory incubator ASAP.

Urinary or CSF "rapid antigen" testing is not recommended because of poor sensitivity and specificity. The laboratory may under some circumstances elect to test CSF antigens when the results may affect public health responses, but these results should not be used to guide the clinical decisions in the care of individual patients.

Other

Full blood count/differential Glucose, urea and electrolytes PT/APTT, DIC screen if appropriate

Later problems

Small vessel thrombosis / tissue loss - involve Plastic Surgery early. Analgesia is important for skin necrosis or peripheral gangrene. Opiate infusions may be needed.

Reactive arthritis or pericarditis may occur in a few patients between days 3 to 7. Fever persisting for more than 7 days -This is common and may be due to: tissue damage (if

there is extensive vasculitis), nosocomial infection, subdural effusion (in the case of

meningitis), other foci of suppuration, or reactive complications. Uncommon causes include inadequately treated meningitis, a parameningeal focus or drugs.

The Infectious Diseases service (ID Fellow – page 5787) would be pleased to hear about all cases and is available for consultation as needed.

Notification

All cases of presumed or confirmed Neisseria meningitidis disease should be urgently notified to the Department of Human Services by telephone on 1300 651160 (fax 1300 651170) (after hours pager 03 9625 5000, pager number 46870).

Link to DHS info on meningococcus Link to DHS notifications (include form)

Contact chemoprophylaxis

It is important that prophylaxis be given within 24 hours to contacts.

All intimate, household or daycare contacts who have been exposed to index Case within 10 days of onset.

Any person who gave mouth-to-mouth resuscitation to the index Case. The index case should also receive prophylaxis if penicillin only was used RCH usually provides prescription for immediate family members and DHS supplies other

contacts. Prophylaxis is provided free from the hospital pharmacy and families should contact

DHS if they have any problems obtaining free supplies outside RCH DHS contact: Infectious Disease Unit: Nurse 03 9637 4124, Medical Officer 03 9637 4127 Infants and children>1 month of age,

Rifampicin 10 mg/kg po 12 hourly (max 600 mg) for 2 days Adults

Rifampicin 600 mg 12 hourly for 2 days Infants < 1 month of age

Rifampicin 5 mg/kg po 12 hourly for 2 days Pregnancy / contraindication to Rifampicin

Ceftriaxone 125 mg (<12 y) / 250 mg (>12 y) intramuscularly as a single dose

Rifampicin causes orange-red discolouration of tears, urine and contact lenses, and may also cause skin rashes and itching, and gastrointestinal disturbance. It negates the effect of the oral contraceptive pill and should not be used in pregnancy, breastfeeding women, or severe liver or renal disease.

At RCH, a supply of rifampicin capsules and syrup is kept in the ICU pharmacy cupboard (bottom shelf right hand side). Immediate families members may be given free supplies (click here for info).

There is a Parent Information Sheet which gives details of meningococcal infection and the use of rifampicin.

Follow-up

See meningitis guidelines for meningitis follow-up. All children with meningococcaemia should be followed up either in outpatients or by a local paediatrician. Those with extensive skin disease may also require input from plastic surgeons, pain specialists, and psychiatrists or counsellors.

Metabolic Disorders

See also: Hypoglycaemia Seizures Resuscitation

Background

Metabolic disorders or inborn errors of metabolism (IEM) result from a block (partial or complete) to an essential pathway in the body's metabolism. There are a large number of conditions included in this group of disorders.

Management of metabolic disorders can be very complicated and should always involve close liaison with a metabolic physician.

Most of these disorders are inherited as autosomal recessive. Many metabolic disorders present in the newborn period or shortly thereafter. Patients may

present later, for example during intercurrent illnesses. High index of suspicion required to make diagnosis as the clinical presentation of most

metabolic disorders is non-specific.

History

Parental history- consanguineous parents, previous unexplained neonatal deaths or Sudden Infant Death Syndrome (SIDS), family history (e.g. relatives with undiagnosed 'syndrome'), ethnic group (certain diseases only)

A metabolic disorder may present differently depending on the age of the child: Neonatal period:

poor feeding/suck or vomiting hypotonia respiratory compromise/apnoea progressive encephalopathy and seizures clinical picture often mistaken for sepsis

Childhood: recurrent unexplained vomiting with severe dehydration stroke like episodes acute liver or renal failure cardiomyopathy unexplained encephalopathy and seizures

Presentation may also be more insidious:

Developmental delay or regression Coarsening of features and skeletal changes Psychiatric disorders An acute metabolic disturbance following a recent dietary change e.g. introduction of

solids, fasting or following excessive physical activity Food craving or refusal

Assessment

Look for

CNS Effects - irritability, changes in consciousness, movement disorder, hypotonia, seizures, coma

GIT- poor feeding, vomiting/ dehydration, prolonged jaundice Developmental- motor/cognitive delay or regression Is there a metabolic acidosis? Is there Hypoglycaemia? Is there ketosis? Is there hyperammonaemia?

Causes

General appearance (e.g. Marfanoid habitus in Homocystinuria), unusual odour (e.g. musty in Phenylketonuria (PKU)), ocular involvement (e.g. cherry red spots in Tay Sachs disease), cataracts (e.g. galactosaemia), hepatosplenomegaly (e.g. Hurler syndrome)

Investigations

Blood, urine and CSF samples collected at the time of presentation may be diagnostic

Blood Acid-base: capillary sample Glucose and lactate: fluoride oxalate tube, 1ml Ammonia: heparinized tube (1ml)- immediately to lab on ice Ketones and free fatty acids: fluoride oxalate tube (2 ml) Electrolytes (including calcium, phosphate, magnesium) plain gel tube (1 ml) Amino acids; heparinised (1 ml sent on dry ice) Insulin, cortisol, growth hormone: plain gel tube (3-4 ml) Full blood count and film (EDTA tube 0.25 ml) Blood drops onto a Guthrie test card (for acyl-carnitine profile)

Leave to dry in room air. Do not store in a plastic envelope. Blood volumes required in different tubes (total approximately 10mls):

capillary acid-base sample (180ul- fill tube) Fluoride oxalate (grey) tube- 3ml Heparinised (orange) tube-2 ml (on ice) Plain gel (brown) tube- 5 ml total (2ml on dry ice) EDTA (pink) tube- 0.25 ml

Urine Ward test for pH, ketones, protein, glucose, reducing substances 5-20ml for amino acids and organic acids

CSF Glucose, protein, lactate (0.5ml) and amino acids (0.5ml clear CSF- sent to lab

immediately on dry ice)

Management

Acute management as per resuscitation guidelines (ABC) if required See Resuscitation Consult with Metabolic Physician and check ED patient alert system Intravenous or nasogastric tube fluids to correct dehydration and replace ongoing losses (e.g.

vomiting, diarrhoea) Ensure adequate amount of calories for age and weight to avoid catabolism (e.g. glucose

solution 10%, intralipid etc.) Hypoglycaemia and/or seizures treated as per guidelines See Hypoglycaemia

Intravenous medications to chelate or divert toxic metabolites, or replenish deficient metabolites, depending on metabolic problem (e.g. Carnitine, Arginine, Na-Benzoate, vitamins etc)

Haemofiltration in ICU may be required if there is a rapid deterioration due to accumulation of toxic metabolites

Notes

The interpretation results of the blood acid-base state, glucose, ketones and ammonia will help classify the type of metabolic disorder.

Interpretation of laboratory results - RCH Clinical Handbook 7th Edn, 2003, Blackwell Science. Metabolic Conditions (p475)

Metabolic condition pH Glucose Ketones Ammonia

Urea cycle defects N or N N

Organic acidaemia , N or N or

Ketolysis defects, MSUD^ N or N or N

FA oxidation defects N or N or N or N or

Hyperinsulinaemia N N N or

Pituitary/adrenal deficiency N N

N = Normal ^MSUD= Maple Syrup Urine Disease

Seek advice from Metabolic Physician if there is a suspected metabolic disorder or if there is a child with a known metabolic disorder who presents acutely unwell.

Death of a child with a suspected metabolic disorder See Death of a child with a suspected metabolic disorder

Molluscum Guideline

Background

Molluscum is a common viral infection of childhood — it is usually a benign and self limiting infection of the skin. Spread is by direct contact, including auto-inoculation. The incubation period is unknown. A child may develop a few or a great many lesions. Most cases resolve spontaneously within 6-9 months, butlesions can persist for more than a year.

Assessment

Characteristic clinical features:

Firm, pearly, dome-shaped papules with central umbilication. Lesions are usually 1-3 mm in diameter, but can grow to 1-2 cm.

Presentation to a doctor is often prompted by the development of eczema in surrounding skin. Recognition can be difficult as these changes can obliterate the primary lesions, however a carefully taken history of the initial lesions is usually diagnostic.

Lesions can occur anywhere, particularly in flexures and areas of friction. Lesions may occur in the anogenital region and are not usually associated with sexual abuse.

Molluscum on eyelid margins can cause chronic conjunctivitis, often unilateral.

Management

The treatment depends on the age of the child, the location of the lesions and any secondary changes.

Most children do not require treatment. Complete resolution will happen when an immune response develops, which may take from 3 months to 3 years.

Secondary eczema should be treated with an appropriate topical steroid (e.g.mometasone furoate 0.1% (Elocon) under medical supervision). Use sparingly for short periods of time.

Individual lesions can be removed by cryotherapy or curettage, with or without topical anaesthesia.

These methods are usually not appropriate for younger children. Other treatments may stimulate the immune response:

benzoyl peroxide 5% daily to small areas and covered with the adhesive part of a dressing.

aluminium acetate solution (Burrow’s solution 1:30) for large areas imiquimod 0.1% cream (expensive and evidence to support its use is limited)

Note: Scarring may be worse following these treatments than with conservative management.

Lesions often become inflamed but antibiotics are rarely necessary. Children with molluscum should not be isolated or restricted in their activities. Avoiding

sharing towels or bathing together may reduce the spread to siblings.

Molluscum

Molluscum is a common skin problem causing small, harmless raised spots.The spots can be present for a few weeks to several months or more than a year. It is caused by the Molluscum Contagiosum Virus (MCV). This virus only lives in humans. It is contagious and can be spread from person to person or to different areas in the same person. It can also be spread by children sharing baths or pools; by bath toys and on towels. Usually it does not need any treatment. Good personal hygiene can help prevent it spreading.

Signs and symptoms

At first the molluscum spots look like pimples. Then they become round, pearl coloured lumps that have a white mark or core in the centre of them. They are usually between 1 to 5 mm in size, but can be as big as 1 - 2 cm wide. Usually they are on the nappy area, tummy, face, arms and legs.

Molluscum spots usually heal without scarring, although a small 'chicken pox' type scar is possible. Scarring is slightly more likely with more aggressive treatment. Molluscum spots are painless but can be itchy - scratching can also cause scarring.

How is it spread?

Molluscum is spread from skin to skin contact when touching the molluscum lumps. Sharing towels and face cloths is another common way to spread the virus. Swimming in pools can also spread it to other children through the pool water. It can take weeks to months from when your child has contact with the molluscum virus to when the spots appear.

Treatment

Most of the time, Molluscum does not need any treatment. The spots usually disappear over a period of time as the body fights and kill the virus. A small number of children can have the spots for several months.

No one treatment is effective for all children. More aggressive treatment may cause scarring and so it is best to try simple treatments first. Simple treatments are designed to irritate the spots. This is to encourage the body's immune system to recognize the virus and destroy the infected cells.

1. Tape stripping Cover the spots with an occlusive tape such as duct tape or elastoplast. The tape is left on for 2 days and then pulled off. This irritates the spots. This may need to be done several times to try to remove the central core of the spot.

2. 'Irritating solutions' If tape stripping by itself is not effective, also applying an irritating solution such as Benzac gel (benzoyl peroxide 10%) or Retin-A (tretinoin cream) to the spots can help. The solution makes the spot become inflamed and needs to be applied carefully to avoid the surrounding skin. The tape stripping then needs to be done each day. See your family doctor first.

3. Aluminium acetate (Burow's solution) If the above two steps do not work, a weak solution of aluminium acetate (Burow's solution) diluted with water (1 part Burow's solution and 29 parts water) can be gently dabbed on to the spots after the shower. Allow the solution to dry, then apply the Benzac or Retin-A and then cover with tape. Repeat once every day.

4. Remove the central core(older children only) In older children, squeezing or removing the central core may help to speed the disappearance of the spots. See your family doctor or dermatologist.

5. Liquid nitrogen freezing Liquid nitrogen is applied to the spots every 2-3 weeks. There is a higher risk of mild scarring. Please see your family doctor or dermatologist.

6. Other creams Other creams are available to treat Molluscum. There is also a slightly higher risk of mild scarring. Please see your family doctor or dermatologist.

Sometimes the skin around the lumps can get a rash like eczema and the skin can become infected. Sometimes antibiotics are used for this skin infection. The antibiotics do not treat the molluscum spots themselves. Sometimes the molluscum is treated because it is irritating your child and because it is easily seen by other people.

At home care

Strict attention to hygiene is very important. Children with Molluscum should do the following:

Have a shower instead of a bath. The Molluscum virus can live and spread in the bath water to other parts of the body.

Wash and dry any bath toys every day after use. Bath toys can spread the virus. Be careful drying your child dry after their shower. The virus can be spread on the towel - try

to dry areas with the spots last. Do not share baths with other children. Do not go into swimming pools until the spots have gone away. Do not share towels, face washers (flannels) or clothing. Wash your hands after touching the Molluscum spots. Children with Molluscum can go to school and play with other children, as clothing usually

covers the affected areas.

Key points to remember

Molluscum spots are caused by a virus. It is spread from person to person by touching the Molluscum. It is also easily spread through

bath or pool water, bath toys and towels. It is not life threatening. The spots can last for weeks to months. Treatment is not always needed. Careful hygiene can help reduce the spread of the infection.

Nappy Rash

Background

Nappy rash is a dermatitis confined to the area covered by the nappy. It is most commonly characterised by confluent erythema of the convex surfaces of the buttocks, the areas of skin in closest contact with the nappy and it spares the groin folds.

Nappy rash is not one distinct diagnosis, but is a multifactorial problem.

Factors which contribute to Primary Irritant Napkin Rash:

Excess skin hydration water in urine & stool nappy change frequency

Skin trauma friction between nappy and skin.

Irritants ammonia (produced from urine by urea splitting organisms in faeces) faeces (especially diarrhoea) soap & detergent residue agents present in Nappy Wipes napkin powders & creams

Candida albicans (present in faeces and infects damaged moist skin)

The relative contribution of each factor may vary between cases. It is not generally helpful to distinguish between these causes of Primary Irritant Napkin Rash as the treatment principles do not depend on this.

Treatment

Use disposable nappies. Increase the frequency of nappy changing and cleansing the skin. Use disposable towels or face washers soaked in water or olive oil to cleanse the area. Application of a barrier cream at every change. Effective barrier creams include zinc paste,

white soft paraffin and vaseline. Apply extremely thick and should not be removed completely after each nappy change, rather apply another layer over the top.

Letting the child spend as long as possible without a nappy on, lying on a soft absorbent sheet that is changed as soon as it is wet. Sunlight plays a role.

If there is associated candidal infection, leading to erythema in the folds and satellite pustules then topical anti-candidal therapy (an imidazole or nystatin) should be applied. This therapy is often combined with 1% hydrocortisone to reduce the associated inflammation.

Consider differential diagnosis (see below)

Differential diagnosis

Seborrhoeic dermatitis - Non-itchy salmon pink flaky patches may appear on the face, trunk and limbs and involves skin folds.

Atopic dermatitis Psoriasis- sharply demarcated, non-scaly, bright erythematous plaques either isolated or

similar lesions in other intertriginous areas such as the axilla etc, Perianal streptococcal cellulitis - localized well-demarcated erythema that covers a circular

area 1-2 cm radius around the anus with fissuring and macerated skin. Can present with painful defecation and/or constipation.

Zinc deficiency - sharply defined, red, often extensive, anogenital rash. Look for perioral, peri-nasal and acral (hand and foot) dermatitis, alopecia, diarrhoea, and failure to thrive.

Threadworms - In older children, threadworms (Enterobius vermicularis) are a common cause of an itchy anogenital rash. Look for the worms at night and treat with oral mebendazole.

Langerhans' cell histiocytosis - a chronic inguinal or anogenital rash, with brownish/red scale and petechiae, which is often erosive and unresponsive to treatment. A scaly, papular, eruption on the scalp or trunk may appear. Purpura, fever, diarrhoea or hepatosplenomegaly may be present.

Malabsorption syndrome - Malabsorption from any cause (e.g. cystic fibrosis) can present with diarrhoea, erosive dermatitis and failure to thrive. There may be a progressive intractable napkin rash contributed to both by the diarrhoea and by secondary nutritional deficiencies

Crohns disease Parent Information Sheet (Print version - PDF)

Nappy rash

The most common cause of nappy rash in babies is irritation. Constant moisture, occlusion and rubbing cause damage to the skin. This is further irritated by bacteria, yeasts (eg Candida or thrush), detergents, urine (wee) and faeces (poo).

Nappy rash is made worse by:

Runny, loose poo (diarrhoea). Not changing the nappy often enough. Plastic pants.

Most children grow out of nappy rash with toilet training.

Signs and symptoms

The skin in the nappy area looks red and raw. It can be generally red, or spotty in appearance, particularly at the edges of the rash.

The body's creases are not usually involved. It can be sore or itchy when the area is wiped. Your baby may be unsettled or irritable.

Care at home

A good quality disposable nappy is best. These allow the moisture to be absorbed quickly, keeping the skin dry. Whilst cloth nappies are good for the environment, they do not take up moisture as well as disposables.

Nappies should be changed often (about 5-7 times a day in babies under 12 months), reducing the contact of urine and faeces with the skin.

At each nappy change your baby's bottom should be gently wiped with cotton wool or 'Chux' type cloths, dampened with luke-warm water. Baby wipes can be quite irritating and should not be used.

A barrier cream should be thickly applied at each nappy change. This will prevent the moisture and irritants from reaching the skin. Zinc paste is the best or white soft paraffin. If the cream wipes off too easily, try another brand, as the idea is to create a barrier. These creams are available from your Pharmacy, or may be prescribed by your doctor.

Try to let your child have as much time without the nappy on as possible. Talcum powder should not be used on nappy rash.

Be aware that other conditions may look like nappy rash and these may not respond to the treatment for nappy rash. If the rash is not improving, see your local doctor or dermatologist.

Treatment / preparations

Nappygoo - The Royal Children's Hospital's own nappy rash cream, developed by and available from the RCH Pharmacy Department.

If prevention is not successful, a medicated cream such as an antifungal (eg Canesten, Daktarin, Nystatin) or hydrocortisone (eg Sigmacort 1%) may be necessary. Do not use any stronger cortisone creams in this area unless your doctor tells you to.

Antiseptics should not be used on nappy rash.

When to come back

See your doctor if the rash does not improve within 1-2 weeks.

Key points to remember

Prevention is most important. A good quality disposable nappy is best. Many rashes can occur in the nappy area. Some of these are conditions which can be found

on any area of the body (eg eczema, psoriasis), whilst others are directly related to the wearing of a nappy.

Persistent Nasal Discharge ('Rhinosinusitis')

Rhinosinusitis is inflammation of the epithelial lining in the paranasal sinuses. It is common in children and is probably under-diagnosed, however it resolves spontaneously in the majority of cases.

There are a number of causes;

Viral Infection

Bacterial Streptococcal Pneumoniae Haemophilus Influenzae (non typeable) Moraxella Catarrhalis

Seasonal Allergic

Perennial

Chemical

Adenoidal Hypertrophy Obstructive

Foreign Body

If recurrent or severe, consider rarer causes:

Anatomical anomalies Immunodeficiency Ciliary dysfunction (Cystic Fibrosis)

Acute Bacterial Sinusitis

This usually follows a viral infection. Mucosal inflammation and thick secretions block the normal sinus drainage resulting in secondary bacterial infection.

Symptoms Signs

Nasal discharge (purulence is of little significance) Inflamed nasal mucosa

Nasal obstruction Pus exuding from the middle meatus

Maxillary toothache Maxillary transillumination (over 9yo)

Unilateral facial pain Associated middle ear changes

Headache

Fever

Diagnosis in younger children is more difficult as the signs and symptoms are non specific. Persistent nasal discharge (beyond 10 days) is usually the predominant symptom. There are a number of causes of this presentation including sequential URTI's, allergic rhinitis and adenoidal hypertrophy.

Complications

Orbital Complications: Periorbital cellulitis , orbital cellulitis (see Orbital Cellulitis Guideline)

Intracranial Complications: Cerebral abscess, cavernous sinus thrombosis, meningitis, encephalitis, subdural / epidural empyema

Investigations

CT is the imaging modality of choice. Air-fluid levels, opacification and mucosal thickening may be seen, however, these findings are non-specific.

CT is not used routinely but may be indicated in the following situations:

failed medical management possible orbital / intracranial complication if surgery is being contemplated

Culturing nasal secretions is not indicative of sinus flora and is therefore not helpful. The 'Gold Standard' would be sinus puncture for culture. This is invasive and painful and should only be done in an ENT setting.

Treatment

1st line amoxycillin (15mg/kg/dose tds) for 10days (Cephalexin if penicillin allergic)

2nd line amoxycillin/clavulanic acid (if pt has had amoxycillin in the last month)

If orbital / intracranial signs

IV flucoxacillin (50mg/kg/dose 6 hourly) and IV cefotaxime (50mg/kg/dose 6 hourly) and refer to ophthalmolgy/neurosurgery

The addition of steroid sprays, decongestants, or antihistamines to antibiotic treatment has been shown to have no benefit in sinusitis.

Surgery is very rarely needed.

Needle Thoracocentesis

See also: Primary Spontaneous Pneumothorax Chest Drain (Intercostal Catheter) Insertion

Notes Equipment Analgesia, anaesthesia and sedation Procedure Post-procedure care

Notes

Needle aspiration (thoracocentesis) is now an established initial intervention in selected patients with primary spontaneous pneumothorax (see Primary Spontaneous Pneumothorax)

It is the only acceptable immediate intervention in cases of tension pneumothorax Tension pneumothorax is a clinical diagnosis. There is a 10 - 20 % chance of causing

a pneumothorax if thoracocentesis is attempted and the child does not have a pneumothorax. This procedure must be followed up by chest x-ray, and will require a chest drain if the patient is ventilated.

Indications:

Primary spontaneous pneumothorax Tension pneumothorax

Relative contraindications:

Thoracocentesis should be only be considered in consultation with a senior emergency physician in the following:

Spontaneous pneumothorax in patients with underlying lung disease Traumatic pneumothorax without tension

Equipment

Dressing pack Aspiration device Large bore cannula (12 or 14 gauge) Central venous catheter (CVC) or Pigtail catheter are alternatives 20ml or 50ml syringe 3 way tap Antiseptic solution 1% lignocaine ampoule Sleek and Tegaderm x 2

Analgesia, Anaesthesia, Sedation

Analgesia and local anaesthesia are mandatory except with tension pneumothorax, which is immediately life-threatening.

Use local anaesthetic or EMLA/ANGEL Consider oral or parenteral analgesia pre- and post-procedure

Procedure

Place patient on continuous cardiac monitoring and pulse oximetry Patient position Place trauma patient in a head-up, supine position All other patients should be placed in 45-degree, sitting position Palpate landmark (the upper border of the 3rd rib in the midclavicular line) and antiseptically

prepare the area Attach a 5ml syringe to the catheter device Puncture the skin at the level of above landmark Carefully insert the needle at a slightly downwards angle into the pleural space while

aspirating the syringe

In tension pneumothorax, often you will hear a pop or feel a change of resistance Withdraw the needle while gently advancing the cannula downwards into position Secure cannula/CVC with tape/tegaderm Attach 3 way tap and 50ml syringe Drain until no further drainage or to a maximum of 30ml/kg (max 2.5l)

Post-Procedure Care

Reassess ABCs

Consider need for further analgesia Plan for chest drain (intercostal catheter insertion) in patients with tension pneumothorax Organise appropriate patient disposition

Trauma guideline Primary Spontaneous Pneumothorax guideline

Needle Stick Injury

Background

All hospital acquired needlestick injuries require an Incident Report form During business hours contact the staff health nurse pager 6663 After hours contact the emergency department consultant/night registrar.

Assessment

Community acquired needlestick injury:

Follow first aid measures as outlined below Source is usually unknown Consider hepatitis B:

If vaccinated check antibody levels If unvaccinated then give 1st dose vaccine and consider immunoglobulin

< 2 yr: 100 units 2 - 10 yr: 200 units > 10 yr: 400 units

Consider tetanus: If immunised within 5 years then no action required If booster 5-10 years; give CDT/ADT If > 10 years give CDT/ADT If unimmunised/unknown then 3 dose vaccination

Take blood from the patient and store. (This blood will be tested only if follow up testing is positive)

Arrange follow-up in Infectious Diseases outpatients in 6 weeks or earlier if counselling is required.

If source known and HIV, hepatitis B or C positive then contact Infectious Disease Fellow/Consultant via switchboard.

Neonates

Neonates - Recognition Of Serious Illness

Neonates at particular risk of serious illness include:

Low birth weight babies (preterm or small for gestational age) Those with a previously recognised medical problem eg. congenital anomaly Babies from socially disadvantaged families.

All infants less than 4 weeks old must be seen by an Emergency Registrar or Consultant. Clinical acumen will not reliably distinguishing ‘well’ from ‘sick’ infants in this age group.

Assessment

The following presenting features are associated with a higher risk of serious illness in young infants:

Fever

Full sepsis evaluation and admission should be considered for any neonate with T>38. Investigations should be performed in the neonatal unit unless there is undue delay or the infant is to be admitted to a general ward.

Feeding

If the volume taken in the previous 24 hours is less than 50% of normal.

Urine output

Less than 4 wet nappies in 24 hours indicates a significant decrease in fluid intake.

Peripheral circulation

Generalized pallor of recent onset, mottling, cold periphery or sluggish capillary return (capillary refill time > 2 seconds).

Responsiveness

Poor response to stimulation; a weak cry.

Activity

Decreased activity/movement and increased sleeping.

Breathing difficulty

The signs of respiratory distress in the neonate are tachypnoea (RR > 60/min), recession, expiratory grunt, nasal flaring and cyanosis.

Apnoea

Defined as a pause in respiration of > 20 seconds. May be central (eg. prems), obstructive (eg. URTI with pharyngeal mucous, GOR, blocked nose) or combined.

Vomiting

Any vomiting in excess of normal post-feed possiting must be treated seriously in the neonate.

Bile-staining indicates bowel obstruction (eg. malrotation with volvulus).

Cyanosis

Seizures

Severe jaundice

Risk of bilirubin encephalopathy, particularly if haemolytic.

Nephrotic Syndrome

Nephrotic syndrome is a clinical disorder characterised by oedema, proteinuria, hypoalbuminaemia and hypercholesterolaemia. Minimal change glomerulonephritis accounts for 80 - 85% of nephrotic syndrome in childhood.

Presentation

Oedema is the primary feature. This may be subtle (peri-orbital region, scrotum or labia) or gross and include in addition, peripheral oedema of the limbs and sacrum. Ascities and pleural effusions may be present when oedema is gross.

History is often of weight gain, poor urine output and sometimes of discomfort as a result of the oedema. A history of preceding upper respiratory tract infection or diarrhoea may be present.

Examination should confirm the presence of oedema, assess peripheral perfusion and blood pressure. Examination should include a search for signs suggesting the onset of complications such as infected ascites, renal vein thrombosis (eg enlarged renal mass, loin tenderness and marked heamaturia) and cerebral vein thrombosis.

Urinalysis should always be included to make the diagnosis as other causes of oedema such as protein losing enteropathy or cardiac failure may occur.

Infections The altered immune system in patients with nephrotic syndrome is responsible for their enhanced risk of infection. Penicillin during oedematous phases is effective prophylaxis.

Thrombosis Renal, femoral, cerebral, pulmonary thrombosis may occur in nephrotic patients due to hypovolaemia, high platelet counts and loss of antithrombin III. Thus low dose aspirin is recommended in oedematous nephrotic patients.

Acute renal impairment This is due to renal hypoperfusion. Albumin is the treatment (see below).

Investigation

1. Urinalysis A finding of +++ or ++++ is usual on dipsticks. The degree of proteinuria is variable. Proteinuria is usually of the selective type. Microscopic haematuria is present in 15 - 20% of patients with minimal change nephrotic syndrome. Red blood cells and granular casts may suggest the alternative diagnosis of chronic glomerulonephritis as the underlying cause for nephrotic syndrome.

2. Estimating proteinuria A timed collection of urine for protein excretion is not necessary when the diagnosis is clear.

3. Routine biochemistry Urea and electrolytes, creatinine, total protein, albumin, globulin, cholesterol.

Treatment

1. Admit to hospital for first presentation. In the case of relapses consult with treating physician. 2. Intravenous albumin is indicated for anuria, hypotension, poor skin perfusion with skin mottling

or poor capillary return. These are all indicators of a depleted vascular space. Give only in consultation with treating consultant. Give 20% albumin 5 ml/kg (1 g/kg) over 4 hr i.v. Beware of the possibility of hypertension and pulmonary oedema. Frusemide should only be given if the peripheral perfusion markedly improves following the albumin or there are signs of pulmonary oedema or hypertension.

3. Gross genital oedema causing discomfort may also be an indication for albumin. Frusemide 1 mg/kg i.v. should be given 2 hr later.

4. Free fluid intake. 5. Diet with no added salt. 6. Oral penicillin 12.5 mg/kg/dose bd (prophylaxis) while oedematous. If the child is profoundly ill

or appears to have sepsis use cefotaxime 50 mg/kg/dose 6-hourly to a maximum of 2 g/dose (to cover Strep pneumoniae, H influenzae and E coli).

7. Low dose aspirin (10 mg/kg alternate days). 8. Strict fluid balance. 9. Daily weight. 10. Corticosteroids

Prednisolone

UNDER REVISION

Relapses

Over 75% of patients will experience at least one relapse, usually in the setting of an intercurrent illness. A relapse is defined as proteinuria ++++ or +++ for 4 days. Lower levels of transient proteinuria with fever do not require re-treatment.

UNDER REVISION

If oedema recurs also restart penicillin and aspirin.

Nitrous Oxide - Oxygen Mix

See also: Ketamine Guideline

Analgesia & Sedation Guideline

Note - at RCH these guidelines are for use in the Emergency Dept. For use in other areas see also Procedural Sedation Guideline

Backgroud

Nitrous oxide has been used for many years in obstetric care during labour. It has both analgesia and amnestic properties. It has a quick onset of action and fast offset which makes it ideal for use in an emergency department. It has no sedative properties and thus must be used on patients who are co-operative (i.e. >4yrs of age).

It comes as a pre-mixed 50:50 combination of nitrous oxide and oxygen on a demand triggered system, or as a continuous flow via a mixer (maximum concentration is 70% NO:30% O2).

Indications

fracture manipulation abscess incision and drainage injection of local anaesthetic removal of foreign bodies from ear / soft tissues other painful procedures

Contraindications

Head injury with LOC or altered conscious state Chest injury or suspicion of pneumothorax Current acute asthma episode

Procedure

Pre-procedure

Patient should be kept nil orally prior to the procedure Either two doctors or a senior nurse & doctor are required - one giving the Nitrous Oxide and

the other performing the procedure.

Entonox (i.e. demand valve)

Check cylinder has a tight seal to the regulator pipe. Can use either an appropriate sized mask or mouth piece. Connect the mask / mouth piece to the filter and then attach filter to the demand valve. Turn the cylinder to the open position and the regulator will record the amount of Nitrous

Oxide left in the tank (if less than 500 KPa then cylinder needs changing).

Continuous Flow Meter

Make sure the oxygen and nitrous oxide tubing are connected to their respective outlets Attach filter and appropriate mask to the circuit Add a few drops of flavouring as needed

Make sure the suction is connected to the "bassoon" on the machine and is on low suction only

Procedure

Entonox (i.e. demand valve)

Patient should self-administer Nitrous Oxide for a few minutes immediately prior to commencement of painful procedure, with a doctor supervising. A harsh sound is heard on inspiration if the gases are flowing properly.

Procedure is performed with patient continuing to breathe Nitrous Oxide for the duration of the painful part of the procedure and 1 minute after painful part of procedure is finished.

Continuous Flow Meter

Turn black knob to allow black bag to inflate. Start with 100% oxygen and have patient breathe regularly through mask; adjust amount of

flow to maintain the bag as being full but not over distended. Bag should empty with patients breath.

Decrease concentration of oxygen with central knob without adjusting the black flow knob. The flow of nitrous and oxygen will be automatically adjusted

Continue decreasing the oxygen (which increases the nitrous) until desired effect felt (ie between 30-50% oxygen (ie 50-70% nitrous))

If using more than 50% nitrous then allow patient to breathe 100% oxygen for 2-3 minutes after procedure has finished

Post- procedure:

Turn the cylinder valve to closed position. The regulator valve will not go back to zero until the line from the regulator to the face mask is emptied.

Patient may be discharged after the procedure is complete if the patient is back to their pre-procedure mental status.

Periorbital & Orbital Cellulitis

Presentation

Management - Orbital Cellulitis

This is a surgical emergency. After consultation with the ENT surgeons and ophthalmologists, an urgent CT scan should be arranged to differentiate those patients with an associated abscess (usually subperiosteal) from those without. This should be discussed with the radiologist who will ask for coronal views. Imaging should pay particular attention to the orbital and frontal regions as the abscess may be small.

Surgical drainage of an abscess results in decompression of the orbit and obtains infected material for Gram stain and culture.

Likely organisms include Strep pyogenes, Strep pneumoniae and Staph aureus. Over 5 years Staph aureus is more common. Haemophilus influenzae type b is less common since HiB immunisation.

Recommended antibiotics

i.v. cefotaxime 50 mg/kg/dose 6-hourly (maximum 2 g/dose) and i.v. flucloxacillin 50 mg/kg/dose 6-hourly (maximum 2 g/dose).

Lumbar puncture is contraindicated in patients with orbital cellulitis until after the CT scan has been performed, even in the absence of features of raised intracranial pressure, since intracranial extension may be silent.

Management - Periorbital Cellulitis

Investigation of these patients should include FBE, blood cultures.

Likely organisms include Strep pyogenes, Strep pneumoniae and Staph aureus. Strep pyogenes and Staph aureus are likely if there is a contiguous skin lesion. Rarely Haemophilus influenzae may be the cause particularly in children under five who are not fully immunised.

Haemophilus bacteraemia-induced periorbital cellulitis and Haemophilus meningitis occasionally coexist. The decision as to whether a lumbar puncture should be performed should be a clinical one.

Recommended antibiotics

Mild Amoxycillin/Clavulanate (400/57 mg per 5 mL) 0.3 mL/kg (11 mL) po 12H

Moderate Flucloxacillin 50 mg/kg (2 g) iv 6H

Severe,

or <5y & not Hib immunised

Flucloxacillin 50 mg/kg (2 g) iv 6H and Cefotaxime 50 mg/kg (2 g) iv 6H

In children who are systemically unwell it may be reasonable to use both cefotaxime and flucloxacillin initially. Any child in whom there is a reasonable suspicion of primary skin infection, or who is not improving on cefotaxime alone should have flucloxacillin added. Failure to respond in 24-48 hours may indicate orbital cellulitis or underlying sinus disease. Treat as for orbital cellulitis.

When improving, and no organism identified change to augmentin 25 mg/kg/dose, 8-hourly (maximum 500 mg/dose) for 7 days.

Prophylaxis

If Haemophilus influenzae type b is isolated, rifampicin prophylaxis should be given as for meningitis, that is, if a child aged 5 years or less lives in the same household as the index case or if the index case is < 2 yr, then prophylaxis should be given to the entire household, including the index case. Parents who are pregnant should not be given rifampicin. Patients should be warned that rifampicin will colour the urine tears and other secretions orange, orange tears may discolour contact lenses. Rifampicin induces the metabolism of the oral contraceptive pill making this form of contraception unreliable.

Doses:

< 1 month: 10 mg/kg once daily for 4 days > 1 month: 20 mg/kg once daily for 4 days Adults: 600 mg once daily for 4 days

All children aged < 5 yr who have not been immunised against Hib should be vaccinated. If children are < 2 yr and have had a documented Haemophilus infection they should be immunised.

Local allergic reactions

In the absence of local and systemic signs of infection eg temperature or tenderness, periorbital erythema may be an allergic reaction rather than periorbital cellulitis.

Osteomyelitis & Septic Arthritis

See also: The Acutely Swollen Joint Hip Pain Upper limb non-use

Osteomyelitis and septic arthritis can affect any joint or bone, but most commonly involve the lower limbs. Both are most commonly caused by Staphylococcus aureus but can be caused by group A b -haemolytic streptococci and Haemophilus influenzae. Children with sickle cell anaemia are prone to infection by salmonellae.

Features

There is considerable overlap in the presentation of osteomyelitis and septic arthritis

Osteomyelitis Septic arthritis

Subacute onset of limp / non-weight bearing / refusal to use limb

Localised pain and pain on movement

Tenderness Soft tissue redness / swelling may

not be present & may appear late +/- Fever

Acute onset of limp / non-weight bearing / refusal to use limb

Pain on movement and at rest Limited range / loss of

movement Soft tissue redness / swelling

often present Fever

Investigations

FBE, ESR (may be useful for monitoring progress), blood culture, xray (often normal, but may exclude trauma, etc), Bone Scan.

NB Consultation and treatment should not be delayed while waiting for a bone scan

Management

Refer to Orthopaedics if osteomyelitis/septic arthritis suspected or confirmed

Septic arthritis requires urgent aspiration +/- arthrotomy and washout* Flucloxacillin 50mg/kg (max 2g) 6 hourly IV (for total 7 days)

Elevate and immobilise limb

Acute Otitis Media

Acute otitis media (AOM) is a common problem in early childhood É 2/3 of children have at least one episode by age 3, and 90% have at least one episode by school entry. Peak age prevalence is 6-18 months.

Causes:

viral (25%) Streptococcus pneumoniae (35%) non-typable strains of Haemophilus influenzae (25%) Moraxella catarrhalis (15%).

Assessment

Note: A child with otitis media can also have serious bacterial infection such as septicaemia or meningitis. If systemically unwell, consider coexistent causes of sepsis - do not accept otitis media as the sole diagnosis in a sick febrile young child without elimination of a more serious cause. (See febrile child guideline)

History:

fever, ear pain (irritability in pre-verbal children) +/- anorexia, vomiting, lethargy.

Examination

The usual middle ear landmarks (handle of malleus, incus, light reflex) are not well seen. The tympanic membrane (TM) is dull and opaque, and may be bulging. The TM colour varies

but is characteristically yellow-grey. On pneumatic otoscopy TM mobility is reduced. There may be associated signs of URTI, such as coryza, red tonsillopharynx, cough etc. The

features suggest the infection is viral. Many febrile or crying children have red TMs (just as they have red cheeks). A red TM alone

is not acute otitis media. It is not usually necessary to remove wax from the ear canals of febrile children

Complications

Perforation of the TM results in purulent otorrhoea, and usually relief of pain. Febrile convulsions are commonly related to AOM. Suppurative complications such as mastoiditis, suppurative labyrinthitis or intracranial

infection (meningitis, extradural or subdural abscess, brain abscess) are very uncommon in our population.

Other potential complications include facial nerve palsy, lateral sinus thrombosis, and benign intracranial hypertension.

Serous otitis media ("glue ear")

Serous middle ear effusion commonly persists for several weeks or even months following an episode of AOM. This may be recurrent, even in the absence of identifiable episodes of AOM, and often causes conductive hearing loss. The long-term effects on language, literacy and cognitive development are unclear. Parental smoking is an important avoidable risk factor. The use of dummies should be limited to settling, as prolonged use has been shown to be associated with otitis media.

Management

Most cases of AOM in children resolve spontaneously. Antibiotics provide a small reduction in pain beyond 24 hours in only about 5% of children treated. The modest benefit must be weighed against the potential harms related to antibiotic use, both for the individual patient (adverse effects) and at a population level (resistance pressure). It has been shown that not using antibiotics for otitis media is acceptable to parents if the reasons are explained clearly.

Pain is often the main symptom, so adequate analgesia is very important Analgesia guideline. Paracetamol 20-30 mg/kg for 2-3 doses/day should be given if pain is significant. Short-term use of topical 1% lignocaine drops applied to the tympanic membrane seems anecdotally to be very effective for severe acute ear pain. Decongestants, antihistamines and corticosteroids have not been shown to be effective in AOM.

The following flow-diagram provides a recommended management scheme:

Ear infections & otitis media

What is 'otitis media'?

Ear infections are very common in small children. Most ear infections involve the middle ear. This is called otitis media.

Babies and young children get more middle-ear infections than older children because the tubes connecting the middle ear to the throat (the Eustachian tubes) are shorter and more horizontal. This makes it easier for germs to reach the middle ear from the nose and throat. The Eustachian tube is also softer in children and gets blocked easily.

This often happens as part of a virus infection (eg common cold), which is very common in early childhood. It is normal to have some fluid in the middle ear, which usually drains down in to the throat. When the Eustachian tube is blocked, this fluid doesn't drain so well and air doesn’t get up into the middle ear space as well as it should.

Signs and symptoms

Babies and toddlers may suffer intense ear pain.

Because of the pain, toddlers can become extremely irritable and hard to deal with. They may have more tantrums. They may pull at their ears or shove their finger inside their ear. Children may also vomit, lose interest in eating, seem to have no energy and have trouble

hearing. Sometimes pus will break through the eardrum so you see a thick yellow discharge from the

ear. When this happens children often feel better as the painful pressure from the fluid inside the ear is gone. The burst eardrum usually heals without treatment.

Middle ear infections often happen with a cold (sometimes called an upper respiratory tract infection or URTI), with a runny nose and sore throat.

Usually they have a fever - sometimes a fever is the only symptom.

Care at home

If your child is in pain give them a pain-reliever such as Paracetamol or Painstop. If you think your child may have an ear infection see your doctor. Many cases of middle ear

infection in children clear up on their own, without antibiotics, over a few days. In some cases a short course of antibiotics may be prescribed, particularly if the child is very

young or very unwell.

Antibiotics are not required every time the doctor notices a child has an ear infection. They may cause side-effects. Ask the doctor if antibiotics are really necessary.

Following an ear infection, children may have some fluid in the middle ear for a few weeks. You may notice your child has some trouble hearing during this time. The fluid will usually clear up over a couple of months. If your child continues to be irritable or does not seem to be hearing well, see your doctor.

Key points to remember

It can be very common for small children to have several ear infections in one year. Antibiotics are not always needed. There may be some fluid in the middle ear for several weeks or months after the infection.

This is normal, and usually clears up on its own.

Glue Ear

Most children will have an occasional ear infection which will get better quickly and are not usually serious. A number of children who have recurrent ear infections will develop otitis media or 'glue ear'.

Glue ear is when children have sticky fluid in their middle ear behind the ear drum. This may last for many weeks or months. It often follows one or more middle ear infections, although it sometimes happens when there does not seem to have been an infection. The fluid in the middle ear makes it harder for your child to hear. When this lasts for a long time hearing and speech development may be affected.

Glue ear will usually become less common as your child gets older.

Signs and symptoms

Many children with glue ear do not have any symptoms. Some children have problems hearing, they may want to have things repeated, talk loudly or

have the television up loud. Parents or teachers may notice this, especially in noisy situations such as classrooms.

Your child may have some pressure or pain in the ear from time to time. In smaller children, hearing difficulties may affect their speech development. Some children seem to be more irritable and have problems sleeping when they have fluid in

the middle ear. A few children with glue ear seem to have problems with balance.

Treatment

You should take your child to visit a paediatrician (children's doctor) or ear, nose and throat (ENT) specialist if:

Your child is having frequent ear infections.

OR

Your child has persistent fluid in the middle ear that affects their hearing.

At this visit the doctor will discuss the following treatment options for your child.

No treatment

If your child is not bothered by the fluid, often no treatment is needed. It usually goes away by itself over time.

Antibiotics

A 2-3 week course of antibiotics is sometimes prescribed to kill any remaining germs. This may help the fluid clear.

Surgery

If the fluid still persists and is affecting your child’s hearing over many months, a brief operation may be suggested. Small ventilation tubes (called “grommets”) are put into your child's ear during the operation. These tubes help fluid drain from the middle ear.

Your child's hearing must be also be tested properly by a hearing specialist called an audiologist.

Care at home

Always try not to smoke in the home or around your child. Any cigarette smoke that your child breathes harms the eustachian tube in th ear so the fluid cannot drain away.

Using dummies for long periods can also make things worse, so only use them for settling your baby.

If your child complains of pain you may need to give them some pain relief, such as Panadol.

Key points to remember about glue ear

Glue ear is caused by frequent ear infections or fluid in the middle ear. Glue ear often needs no treatment. Sometimes a small operation can help drain the fluid from the ear. Hearing and speech development can be sometimes affected if glue ear is persistent.

The Acutely Swollen Joint

Acutely swollen joints may reflect local pathology (eg. trauma, sepsis) or generalised pathology localised to a joint(s) (eg. vasculitis, post-infective arthritis). The differential diagnosis is wide and making a precise diagnosis in the acute situation can be difficult. Often the diagnosis only becomes apparent with time and initial treatment is on a presumptive basis. For a significant number of patients this involves symptomatic measures only.

In the acute phase the most important tasks are to identify those conditions requiring more than just symptomatic treatment, and to ensure that those being treated symptomatically have appropriate follow-up.

Notes on investigations

FBE

Leukocytosis/left shift often found in sepsis and in many reactive arthritides Usually normal in HSP and serum sickness Often have thrombocytosis and mild anaemia in JCA Cytopenias and absence of thrombocytosis in presence of elevated inflammatory markers

suspicious of malignancy

ESR/CRP

Usually elevated in sepsis Usually normal in HSP Often elevated in reactive/post infectious arthritis

click to see flow chart

Elevated in JCA and often in leukaemia

Disposition

Patients with the following conditions should be referred to the appropriate in-patient unit: Joint trauma (orthopaedics) Intra-articular bleeds (orthopaedics/haematology) Joint sepsis (orthopaedics) Suspected malignancy (haematology-oncology) Other (general medicine)

Consider outpatient referral to Rheumatology if:

Symptoms for >4 weeks A significant joint effusion Significant limitation of activity Multiple joint involvement Evidence of joint contractures Vasculitis other than HSP

In many cases there may not be a clear diagnosis by the end of the child’s assessment in the emergency department - the results of some investigations may not be available for days, and others may help only in ‘ruling-out’ certain conditions. For such children, symptomatic outpatient treatment with non-steroidal anti-inflammatory drugs (eg. naproxen) with careful follow-up is appropriate. These children should be followed closely until their symptoms resolve or the diagnosis becomes clear.

Any child with symptoms not resolved after four weeks or any child in whom NSAIDs do not provide adequate relief of symptoms should be re-evaluated.

Upper Limb Non-Use

Acute loss of upper limb movement usually reflects local pathology

Fracture Pulled elbow Joint pathology Infective process Neurological lesion

Do not forget to examine the clavicle

click to view full size

Radiology:

Pay particular attention to the supracondylar fat pads, the radial neck and the distal radius as bony injuries in these areas are the most common differential diagnoses.

Paracetamol Poisoning

See also General Management of Acute Poisoning Guideline

Patients Requiring Treatment (administration of charcoal)

acute ingestion of 150mg/kg or more ingestion of unknown quantity ingestion of 100mg/kg or more if known liver disease, anorexia, alcohol abuse, CF, or on

anticonvulsant or barbiturate therapy, or recent high intake of paracetamol.

Management (see flow diagram***)

Activated charcoal 1g/kg immediately if less than 1 hour since ingestion of tablets or capsules. (Not useful for liquid ingestions as fully absorbed within 20-30 mins).

Serum paracetamol level at (or as soon as possible after) 4 hours post ingestion will determine the need for N- acetyl cysteine administration (see nomogram below)

There is nothing to be gained by measuring serum paracetamol before 4 hours N-acetyl cysteine treatment should not be started unless the nomogram indicates a potentially

toxic paracetamol level If N-acetyl cysteine treatment is required, do APTT/INR and baseline LFT’s upon insertion of

IV. N-Acetyl cysteine (see chart)

Loading dose 150mg/kg in N/2 saline and 5% dextrose (10mls/kg) IV over 1hr. Infusion 10mg/kg/hr in N/2 Saline and 5% Dextrose (at half maintenance rate) for 20

hrs, longer if >10 hrs post ingestion or encephalopathic. Monitor hydration and treat as indicated.

Note

Anaphylactoid reactions to N-Acetyl cysteine may occur (wheeze, rash): stop the infusion for 30 minutes & give promethazine (phenergan) 0.2 mg/kg i.v. then recommence infusion at half the previous rate. Increase the rate slowly over time until the desired rate is again reached.

Nomogram For Paracetamol Poisoning

Check you are using the correct units micromols/Litre A level of over 1300 at 4 hours requires treatment (1000 for high risk patients) (for acute single dose ingestions only - multiple doses over time need an individualised approach - seek advice)

N-Acetyl cysteine (NAC) infusion chart

Weight(Kg) Loading dose NAC (mg)

In mls of N/2 saline + 5% dextrose

Give over 1 hour

Infusion dose NAC (mg) in

1 litre of N/2 saline +5% Dextrose

Infusion rate (mls per hour) for

20 hours approx half

maintenance rate

6 900mg in 60 mls 5000 12

8 1200mg in 80 mls 5300 15

10 1500mg in 100 mls 5000 20

15 2250mg in 150 mls 6000 25

20 3000mg in 200mls 6600 30

25 3750mg in 250 mls 8300 30

30 4500mg in 300 mls 8500 35

35 5250mg in 350 mls 10000 35

40 6000mg in 400 mls 10000 40

45 6750mg in 450mls 11250 40

50 7500mg in 500 mls 11100 45

55 8250mg in 500 mls 12200 45

60 9000mg in 500 mls 12000 50

Click here to view full size pdf file (21KB) Whooping Cough (Pertussis)

Notes Assessment Diagnosis Management Treatment of contacts Notification

Notes

Caused by the bacterium Bordetella pertussis. Infants less than 6 months of age are at greatest risk of complications (eg. apnoea, severe

pneumonia, encephalopathy) and death. Can occur in immunised children but illness is generally less severe. Patients are infectious just prior to and for 21 days after the onset of cough, if untreated. The cough may persist for months.

Assessment

Diagnosis is largely clinical - usually made on the basis of history and observation of coughing spasms.

History

There is generally a history of dry cough and nasal discharge for approximately one week (coryzal phase), followed by a more pronounced cough which may occur in spells or paroxysms (paroxysmal phase).

Vomiting often follows a coughing spasm. Young infants may develop apnoea. Other family members frequently also have a cough (70 – 100% of household contacts are

usually infected).

Examination

Often, there are no clinical signs. Children are usually well between coughing spasms.

Investigations

A nasopharyngeal aspirate for immunofluorescence and culture is the investigation of choice. The organism is usually undetectable after 21 days, or if effective antibiotic therapy against B. Pertussis has been commenced.

Serology rarely affects clinical management.

Diagnosis

Laboratory confirmation is not necessary for diagnosis. Clinical diagnosis can be made on the basis of

an acute presentation with features as outlined above a longer history of cough lasting 14 days without another apparent cause and any

one of: paroxysms; whoop; or post-tussive vomiting.

Managment

Hospital admission

Infants less than 6 months of age, and older infants and children who are unwell require hospital admission.

Antibiotics

Treatment with macrolide antibiotics reduces the period of infectivity but has not been shown to alter the course of the illness unless commenced before the paroxysmal phase.

When treated with antibiotics, the period of infectivity usually lasts 5 days or less after commencement of therapy.

Who should be treated?

In general antibiotics should be considered for Any child admitted to hospital.

Any child with a history of cough for less than 14 days (treatment in these cases will reduce the period of school/day-care exclusion.)

The recommended antibiotic is

Clarithromycin 7.5 mg/kg twice daily for 7 days.

Control of case

The child should be excluded from school and from the presence of others outside the home (especially infants and young children) until he/she has received at least 5 days of a 7-day course of clarithromycin. NOTE: A child who has been coughing for more than 21 days is no longer infectious; therefore antibiotic treatment and school exclusion are not necessary.

Vaccination

Unimmunised or partially immunised children diagnosed with pertussis are still required to complete the pertussis immunisation schedule.

Treatment of Contacts

Vaccination

Close contacts under 7 yrs of age who are not up to date with their pertussis immunisation should be given DTPa as soon after exposure as possible.

Antibiotics

Contacts - Who should be treated?

Antibiotics should be given to all household contacts and to other contacts in high-risk settings who have had direct contact with an infectious case i.e:

Infants <12 months of age who have not received 3 documented doses of pertussis-containing vaccine (maternal antibodies do not protect against pertussis).

Any unvaccinated or partially vaccinated person with chronic cardio-respiratory illness. Any women in the last month of pregnancy.

The recommended antibiotic is

Clarithromycin 7.5 mg/ kg twice daily for 7 days

NOTE: Antibiotics should be given within 14 days * of the recipient’s first contact with an infectious case. (*In special circumstances, such as a high-risk exposure for an infant contact, antibiotics may be given within 21 days of first contact with an infectious case.)

School exclusion

Unimmunised siblings less than 7 years of age and unimmunised close child care contacts must be excluded from school or child care for 14 days from the last exposure to infection, or until they have taken 5 days of a 7 day course of antibiotics. A child who has received <3 doses of a pertussis-containing vaccine should be considered unimmunised.

Notification

Notify all cases (suspected or confirmed) to the Communicable Diseases Section, DHS, Victoria. Tel: 1300 651 160 or Fax: 1300 651 170.

Link to DHS notifications (include form)

Sore Throat

See also: febrile child guideline

A sore throat is an extremely common symptom that frequently results in a medical consultation and prescription of antibiotics. The commonest cause of a sore throat in children is a viral illness. 15 – 30% of children with a sore throat will have Group A streptococcal (GAS) pharyngitis. Bacterial causes for sore throat other than GAS are rare.

Currently there is controversy regarding the appropriateness of antibiotic therapy for GAS pharyngitis in a population where acute rheumatic fever is rare.

Assessment

view flowchart

Antibiotic treatment of group A streptococcal pharyngitis

Antibiotic Dosage Duration Notes

Children (< 10 years) 250mg orally bd

10 days

Penicillin (phenoxymethyl)

Children (> 10 years) 500mg

10 days

orally bd

Erythromycin 20 mg/kg (max 250 mg) orally bd

10 days Use if child allergic to penicillin

Procaine penicillin 50 mg/kg (max 1.5 g) IM

1 dose Use if child unable to tolerate oral medications.Follow injection with course of oral penicillin

Benzathine penicillin G

G 20 mg/kg (max 900 mg) IM

1 dose Use if child unable to tolerate oral medications

Pneumonia Guideline

In A Previously Well Child Aged More Than One Month

Consider pneumonia in infants and children with:

Fever and cough (or difficulty breathing); tachypnoea, nasal flaring, lower chest indrawing or recession, consolidation or effusion: persistent fever; fever and upper abdominal pain;

Notes:

Chest X-ray (AP) should be performed to confirm or exclude pneumonia

Patients with wheeze and air trapping, most commonly have bronchiolitis or asthma:

All neonates who are unwell, or have a temperature > 38C, should have a chest X-ray as part of a septic workup: Management of Pneumonia - flowchart 1

Management of Pneumonia - flowchart 2

Return to Pneumonia Guideline

Primary Spontaneous Pneumothorax

See also: Chest Drain Guideline Needle Thoracocentesis Guideline

Background

Primary spontaneous pneumothorax (PSP) is a pneumothorax occuring in patients without underlying chronic lung disease when there is no provoking factor, such as trauma, surgery, or diagnostic intervention.

Assessment

Most episodes occur at rest. Consider PSP in patients with the following:

Symptoms

Acute onset of chest pain - Severe and/or stabbing pain, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic)

Sudden shortness of breath Anxiety, cough, and vague presenting symptoms (eg, general malaise, fatigue) are less

commonly observed.

Signs

General appearance may be normal Sweating, tachypnoea, tachycardia (most common finding) Splinting chest wall to relieve pleuritic pain Asymmetric lung expansion - mediastinal and tracheal shift to the contralateral side with a

large pneumothorax Decreased or absent breath sounds Hyperresonance on percussion

Imaging Studies

Chest radiograph (confirms pneumothorax) A linear shadow of visceral pleura with lack of lung markings peripheral to the

shadow may be observed, indicating collapsed lung. In supine patients, deep sulcus sign with radiolucency along costophrenic sulcus may

help to identify occult pneumothorax. Mediastinal shift toward the contralateral lung may also be apparent. Small pleural effusions are commonly present and increase in size if the

pneumothorax does not reexpand. CT scan is not recommended for routine use. Methods to estimate the fractional size of pneumothorax are controversial:

Any estimate of size should be performed in conjunction with a senior doctor in the emergency department.

There are currently two methods described in adults: If lateral edge of lung is > 2cms. from thoracic cage, then this implies

pneumothorax is at least 50%, and hence large in size. or

Calculate the ratio of the transverse radius of the pneumothorax (cubed) to the transverse radius of the hemithorax (cubed).

To express the pneumothorax size as a percentage, multiply the fractional size by 100.

Management

See Algorithm

Notes

Small pneumothorax is equivalent to <30% This protocol excludes:

Age < 12 years Underlying lung disease

CF Chronic neonatal lung disease Asthma Others

Trauma Foreign body inhalation

All discharged patients should have appropriate follow-up - please discuss with ED consultant or fellow.

Primary Spontaneous Pneumothorax

See also: Chest Drain Guideline Needle Thoracocentesis Guideline

Background

Primary spontaneous pneumothorax (PSP) is a pneumothorax occuring in patients without underlying chronic lung disease when there is no provoking factor, such as trauma, surgery, or diagnostic intervention.

Assessment

Most episodes occur at rest. Consider PSP in patients with the following:

Symptoms

Acute onset of chest pain - Severe and/or stabbing pain, radiating to ipsilateral shoulder and increasing with inspiration (pleuritic)

Sudden shortness of breath Anxiety, cough, and vague presenting symptoms (eg, general malaise, fatigue) are less

commonly observed.

Signs

General appearance may be normal Sweating, tachypnoea, tachycardia (most common finding) Splinting chest wall to relieve pleuritic pain Asymmetric lung expansion - mediastinal and tracheal shift to the contralateral side with a

large pneumothorax Decreased or absent breath sounds Hyperresonance on percussion

Imaging Studies

Chest radiograph (confirms pneumothorax) A linear shadow of visceral pleura with lack of lung markings peripheral to the

shadow may be observed, indicating collapsed lung. In supine patients, deep sulcus sign with radiolucency along costophrenic sulcus may

help to identify occult pneumothorax. Mediastinal shift toward the contralateral lung may also be apparent. Small pleural effusions are commonly present and increase in size if the

pneumothorax does not reexpand. CT scan is not recommended for routine use. Methods to estimate the fractional size of pneumothorax are controversial:

Any estimate of size should be performed in conjunction with a senior doctor in the emergency department.

There are currently two methods described in adults: If lateral edge of lung is > 2cms. from thoracic cage, then this implies

pneumothorax is at least 50%, and hence large in size. or

Calculate the ratio of the transverse radius of the pneumothorax (cubed) to the transverse radius of the hemithorax (cubed).

To express the pneumothorax size as a percentage, multiply the fractional size by 100.

Management

See Algorithm

Notes

Small pneumothorax is equivalent to <30% This protocol excludes:

Age < 12 years Underlying lung disease

CF Chronic neonatal lung disease Asthma Others

Trauma Foreign body inhalation

All discharged patients should have appropriate follow-up - please discuss with ED consultant or fellow.

Acute Poisoning - Guidelines For Initial Management

See also the following Poisoning Guidelines:

Alkalis Anticonvulsants Antihistamines/antihistamine-decongestant Preparations/Sympathomimetic Agents Benzodiazepines Camphor Ethanol Eucalyptus Oil / Essential Oils Hydrocarbons Iron Paracetamol Salicylates Theophylline Tricyclic Antidepressants

TOXNET

General Principles

Assess:

Type of ingestion (drug, preparation) Time of incident Amount of ingestion (include all medication that was potentially in the bottle or packet when

calculating) Weight of child Is the ingestion potentially harmful? Beware of the possibility of mixed overdose Beware of the possibility of inaccurate dose reporting on history taking If mixed or undetermined ingestion Paracetamol level should be done.

The poisons information centre may provide useful information on toxins and doses found in various products, phone 131126.

Management

Airway Breathing Circulation Removal of poison (if necessary) Emesis

No role in the hospital setting Activated Charcoal

The treatment of choice for most ingestions. Most effective when given within first hour. Contraindications:

Patients with altered conscious state The following agents:

Ethanol/glycols Alkalis Boric acid Lithium Iron compounds Potassium and other metallic ions Fluoride Cyanide Hydrocarbons Mineral acids

Whole Bowel Irrigation has a limited role in treatment of some slow release preparations Gastric Lavage has a very limited role in treatment and should not be used without

consultation. Specific antidotes may be available and serum drug levels may help in treatment decisions

All acts of deliberate self harm must be taken extremely seriously.

All intentional self poisonings in adolescents require admission under the adolescent unit after discussion with their on-call consultant.

If unexplained symptoms exist a urinary drug screen may be indicated..

Sedation - Procedural Sedation Guideline

1. Introduction 2. Goals of Sedation 3. Definition of Terms 4. Indications, risk assessment and exclusion criteria 5. General patient assessment 6. Fasting 7. Preparation of the child and parent 8. Consent 9. Staffing 10. Medications 11. Preparation of venue and equipment 12. ‘Time Out’ and ‘Positive Identification’ 13. Observation and Monitoring 14. Documentation 15. Transport 16. End of sedation criteria 17. Discharge criteria 18. Links 19. Acknowledgements

1. Introduction

The RCH Procedural Sedation Guideline provides hospital staff with the minimum standards for use of sedation of patients outside theatre, ICU, ER and NNU. This Guideline relates to the use of oral agents, inhaled nitrous oxide and intravenous midazolam. Other techniques may be employed in critical care areas and according to Hospital Guidelines for specific procedures. This Guideline is intended for use in patients who are generally healthy or have only mild systemic disease. Sicker patients should not be sedated without the involvement of staff from the Children’s Pain Management Service (CPMS).

Sedation is a continuum ranging from minimal anxiolysis to a state of deep sedation. The response to sedative drugs is not always predictable, so staff need to be prepared to deal with a patient who becomes more sedated than intended. Excessively sedated patients may lose their protective airway reflexes and be at risk of adverse effects including hypoventilation, apnoea, airway obstruction, aspiration and cardiovascular impairment.

The goal of this guideline is to:

Define the patients who are appropriate to receive minimal to moderate sedation for procedures.

Outline the staffing levels required to safely administer the sedation for procedures and indicate which agents need specifically accredited staff members for administration and monitoring of the child.

Summarise the minimum standards for procedural sedation including patient monitoring and observations.

For all stages of the procedure (before, during and after) appropriate non-pharmacological pain management techniques is also required.

The drugs used and their administration should be less noxious than the procedure itself.

If at any time you have uncertainties about the patient's suitability for sedation, or about your own capabilities to conduct the procedure safely - discuss with CPMS (Children’s Pain Management Service) before proceeding.

2. Goals of Sedation

to minimise physical discomfort or pain for procedures to control behaviour, particularly movement to minimise psychological disturbance & distress to maximise the potential for amnesia to administer sedation in a safe manner

3. Definition of Terms

Sedation Period: The period of time commencing with the administration of sedative drugs and ending when the patient has recovered to the point where he or she meets the end of the sedation criteria (observations are within normal limits, patient returns to baseline sedation score).

Minimal sedation (‘anxiolysis’) — Sedation Score 1 (UMSS)

A drug-induced state during which patients may respond normally to verbal commands Cognitive function and coordination may be impaired Respiratory and cardiovascular functions are minimally affected.

Moderately sedated ("conscious sedation") — Sedation Score 2 (UMSS)

A drug-induced state of depressed consciousness with preserved airway protective reflexes. Patients may be somnolent/sleeping but easily aroused with light tactile stimulation or simple

verbal command.

NOTE: It is possible for patients to progress from a state of moderate sedation into a state of deep sedation/obtundation.

Deep sedation — Sedation Score 3 (UMSS)

A drug-induced state of depressed consciousness from which the patient is not easily aroused.

Deep sedation may be accompanied by partial or complete loss of protective airway reflexes. Patients are usually unable to respond purposefully to physical stimulation or verbal

commands.

IMPORTANT: If the aim of sedation is for 'deep sedation' it should only be administered by senior staff in ED, ICU, NNU or Dept of Anaesthesia and Pain Management. Deep sedation’s associated risks are indistinguishable from those of general anaesthesia. Patients receiving deep sedation should also have an IV line in place and remain in that speciality location for the full duration of the sedation period. They should not be transported during the sedation period.

Competent staff member: a staff member who has the knowledge, skills and training to:

observe the patient’s level of sedation perform observations (vital signs) maintain airway patency know how to call for additional help when required and commence resuscitation if required in the pharmacology of the sedative agents to be used, their adverse effect profiles, and the

use of appropriate antagonist agents.

Accredited staff member: a staff member who has:

attended the Royal Children’s Hospital Procedural Sedation lecture. successfully completed the Royal Children’s Hospital Sedation package. safely administrated nitrous oxide/IV midazolam on 3-5 occasions, as assessed by designated

nitrous oxide educator. participates in annual re-accreditation.

4. Indications, risk assessment and exclusion criteria

Indications

Examples of suitable procedures for which procedural sedation is indicated: Lumbar puncture, bone marrow aspiration, wound dressing care, dental extraction, echocardiography, electrophysiological studies, diagnostic radiology, IV access, intercostal catheter removal, skin biopsy.

The procedure should not be complex, very painful or prolonged (? beyond 30 minutes). It is unreasonable to expect sedation to be sufficient in these situations. Patients who are extremely anxious prior to the procedure may need special consideration. General anaesthesia may be required instead.

Risk assessment

Sicker patients should not be sedated without consulting Children’s Pain Management Service (CPMS). The risk assessment will provide you with some guidance. Any risk identified below, needs to be discussed with CPMS. If in doubt also consult CPMS — pager 5773.

Increased risk of delayed gastric emptying or vomiting (which may increase risk of aspiration) e.g. bowel obstruction or gastro-oesophageal reflux

Significant respiratory disease e.g. upper airway obstruction, airway infection, apnoea, exacerbation of asthma, pneumonia

Significant cardiovascular impairment e.g. pulmonary hypertension, cardiomyopathy, hypovolemia

Abnormal conscious state/risk of raised ICP e.g. head injured, meningitis, space occupying lesion

Acute systemic infection e.g. sepsis

Prior adverse event

Prior allergic reaction

Patient receiving opioids or other sedative agents

Age less than or equal to 6 months (for oral agents)

Age less than or equal to 2 years (for nitrous oxide and IV midazolam)

(Refer to Record of Sedation for Procedure MR56S)

Exclusion criteria for nitrous oxide

A patient with a condition which results in ‘trapped gas’ should not receive nitrous oxide, as it will expand the gas filled cavity e.g.lung cyst, bowel obstruction, middle ear disease, pneumothorax

(Refer to Record of Sedation for Procedure MR56S)

5. General Patient Assessment

The treating medical team who request the patient to have the procedure with sedation will usually perform a patient assessment.

The following should be included in the assessment:

prior illnesses and conditions (refer to risk assessment and exclusion criteria ) drug history drug allergies (recorded on Medication Chart) pathology results e.g. platelet count prior to lumbar puncture last food/fluid intake (refer to Fasting times) previous sedation experiences and drugs used accurate weight (recorded on Medication Chart) vital signs

6. Fasting

For ward patients and outpatients fasting times are:

Oral agents: 2 hours solids and liquids

IV midazolam and nitrous oxide: 6 hours solids, 4 hours breastfeed, 2 hours clear fluids

7. Preparation of the child and parent

Adequate preparation and education of the patient and family should be provided - provide age appropriate information about the procedure and any sensations to expect.

Sedation handout must be discussed with patient/parents (www.rch.org.au/kidsinfo) Non-pharmacological techniques should be planned and employed during procedures to

complement and sometimes prevent the need for drug sedation Parents should be encouraged to be present during the procedure to allay anxiety and they

should be taught to coach their child effectively in the use of coping methods. — Procedure Pain Management Guideline.

8. Consent

Informed and written consent for BOTH sedation and the procedure are to be obtained by medical staff.

A Registered Nurse may also obtain informed consent for BOTH the sedation and the procedure if:

the Registered nurse is competent/accredited for the prescribed sedation agent a Registered Nurse is responsible for performing the procedure (i.e. it is not a medical

procedure)

Refer to RCH Consent - Informed Policy

9. Staffing

A minimum of two staff should be present for procedures for which a child is sedated.

One staff member is responsible for performing the procedure.

The other staff member must be responsible for administration of the sedative drug and continuously responsible for observation for the duration of the "Sedation Period". The appropriate training for this staff member will vary according to the sedative agent given.

For oral agents: 2 staff required, 1 competent RN or medical staff member

For nitrous oxide: 2 staff required, 1 accredited staff member

For IV midazolam: 2 staff required, 1 accredited staff member

10. Medications

Patients should not receive sedative drugs prior to arrival at hospital. All sedative agents should be recorded on Medication Chart (MR52) If appropriate, local anaesthetic cream (e.g. AnGel) may be used to help limit the amount of

sedation and analgesia required. Adequate analgesia should also be provided.

11. Prepare venue and equipment

The Venue:

Should ideally be a hospital treatment room with appropriate lighting (adequate lighting for the procedure and patient observation) and minimal noise.

Facilities for observation should be available and used until the child has recovered from sedation to a point where it is safe to be discharged from that area.

The child should have an appropriate size bed or trolley. Sedated patients should not be left to wait in corridors or waiting rooms and ideally not

transported within the hospital.

The Equipment:

Prepare procedure equipment before patient enters the room. Ensure emergency equipment is present and functioning

suction device appropriate size bag and mask O2 available and means to deliver it pulse oximetry blood pressure monitoring (IV midazolam only) resuscitation trolley

Ensure a distraction box is available with age appropriate toys/distraction agents.

12. ‘Time Out’ or ‘Positive Identification’

The TWO staff members involved in the procedure (the proceduralist and the person administering the sedation) will confirm the following corresponds with the Consent Form MR132:

The patient's identity checked via ID band or positive identification The procedure to be performed and sedation agent to be given. Mark procedure side if applicable.

For further information refer to the ‘Consent Checking Procedure’ and/or the ‘Patient Identification’ Policies.

13. Observations and Monitoring

Prior to the sedation

Document baseline vital signs on observation chart (MR 77 or MR52B) immediately prior to commencing sedation.

During sedation period

Drugs administered by competent/accredited staff member. For oral agents, the patient must remain in-line of sight to the nurse throughout the Sedation

Period. Document sedation score on observation chart every 5 minutes (MR77 or MR 52B).

If sedation score e 2, record 5 minutely observations: SpO2, HR, RR (and BP for IV midazolam)

Sedation Score - University of Michigan Sedation Score (UMSS)

1 Awake and alert.

2 Minimally sedated: may appear tired/sleepy, responds to verbal conversation and/or sound.

3 Moderately sedated: somnolent/sleeping, easily aroused with light tactile stimulation or simple verbal command.

4 Deep sedation: deep sleep, rousable only with deep or significant physical stimulation.

5 Unrousable.

14. Documentation

Complete ‘Record of Sedation for Procedures’ (MR56S) Ensure a consent form is signed (also refer to Consent - Informed policy)

Sedative drugs must be prescribed on the patient’s Hospital Medication Chart (MR52) Monitor observations (as above) and record on the observation chart (MR77 or MR52B)

15. Transport

If patients in the "Sedation Period" need to be transported, use a trolley with suction and oxygen, bag and mask apparatus available and pulse oximetry. They should be accompanied by a competent staff member who must be continuously responsible for observation of the patient’s heart rate, airway patency, adequacy of ventilation, and level of sedation, and be able to initiate resuscitation procedures and know how to call for additional help.

Patients under deep sedation should not usually be transported during the sedation period unless clinically necessary.

16. End of Sedation Criteria

Line of sight nursing, observation and recording sedation score (+/- vital signs) can cease once when the patient meets the following criteria:

Observations are within normal limits Patient returns to baseline sedation score or mental status.

If the patient is returning from the treatment room to the general ward, ensure that the allocated staff member has a handover about the sedation and procedure performed.

17. Additional Criteria for Discharge

For Outpatients:

Discharge home may be considered (provided other medical factors permit) when the patient meets End of Sedation Criteria as well as the following criteria:

Satisfactory travel arrangements and supervision for patient confirmed Post sedation handout should be discussed with parents. Safety and injury prevention

highlighted.

Pulled Elbow

History:

Age: usually 1 to 4 years old In 50%: no history of a "pull" on the arm

Examination:

not using the affected limb elbow in extension and the forearm in pronation distressed only on elbow movement

no swelling, deformity or bruising of the elbow or wrist on palpation tenderness is usually absent (remember the clavicle) marked resistance and pain with supination of the forearm.

Manipulation during triage or xray may reduce the subluxation.

Differential Diagnosis:

See upper limb non-use guideline

Diagnosis

Clinically established with a classic history and examination. Plain radiographs are indicated when a differential diagnosis is suspected:

significant tenderness, swelling, bruising or deformity reduction fails

Treatment

Perform a reduction manoeuvre (see below) expect distress and pain a click may be felt over the radial head review after ten minutes if reduction fails, consult with senior medical staff

Reduction manoeuvres

Either of the following methods may be effective

pronation/ flexion manoeuvre

sit the child on the parent's lap

apply pressure over the radial head

fully pronate forearm and then flex the elbow

supination/flexion manoeuvre

sit the child on the parent's lap

apply pressure over the radial head

supinate the forearm

flex the elbow

Urinary Tract Infection Guideline

Notes Assessment Treatment

Investigation Specimens Dipstick Urine Test Other Resources

Notes:

You must obtain a definitive diagnosis by culture of urine obtained in a sterile fashion (MSU, SPA, CSU - see below).

UTI cannot be diagnosed on symptoms alone, nor by culture of urine from a bag specimen. Urinary dipstick testing is only a screening test for UTI. It has poor sensitivity and specificity

(see below). Finding a UTI in a sick child does not exclude another site of serious infection (eg meningitis).

Remember that 2% of young children will have asymptomatic bacteruria and this may not be the cause of this acute presentation. Organisms may spread from urinary tract to elsewhere including meninges. Do not omit an LP in a sick child just because you have found a UTI.

Prior antibiotic therapy may lead to negative urine culture in patients with UTI. The laboratory will test for antibacterial activity in the urine.

Assessment

History

Features are often non-specific such as fever, irritability, poor feeding, and vomiting. More specific features may include loin or abdominal pain, frequency and dysuria. These are

often absent in younger patients. Some children with urinary tract infections may look quite well, while others may appear very unwell.

Examination

Is often normal other than the presence of fever. Loin or supra-pubic tenderness may be present

Treatment

Any child who is unwell, and most children under 6 months, should be admitted for i.v. antibiotics. Include blood culture, electrolytes and consider an LP.

A shocked child will require fluid resuscitation. Discuss children with known underlying urinary tract abnormalities with registrar or consultant. Gentamicin 7.5 mg/kg (240 mg) iv daily and benzylpenicillin 50 mg/kg (3g) iv 6 hourly for

children over 1 month of age. Remember gentamicin levels. If oral medication is appropriate

Trimethoprim 4mg/kg (150mg max) BD (only tablets generally available) or

co-trimoxazole (200/40 mg in 5 ml) 0.5 ml/kg (20ml max) BD or

Cephalexin 15mg/kg (500mg max) TDS.

For 1 week

Check antibiotic sensitivities and adjust therapy in 24 to 48 hours.

For children who are still in nappies: A prophylactic dose of antibiotic eg. co-trimoxazole (200/40 mg in 5 ml) 0.25 ml/kg in a single daily dose, or nitrofurantoin 3 mg/kg at night should be maintained until the child is seen for follow up.

Investigation

All children with first UTI

Renal ultrasound is usually performed in young children after first UTI, especially those under 4 years of age. The main purpose of ultrasound is to exclude urinary tract obstruction.

The following patients should have a renal ultrasound prior to discharge from RCH:

Those less than 6 months of age (especially boys). Those who are particularly sick (needs consent of medical consultant)

All others (ie most cases) should have their ultrasound performed as an outpatient. Usually the most practical and convenient arrangement is for the ultrasound to be performed earlier on the day of outpatient follow-up.

Micturating cysto-urethrogram (MCU) may be necessary but the decision to perform this invasive and sometimes distressing investigation needs to be individualised. The value of demonstrating vesicoureteric reflux in assisting future management is controversial. It is currently a matter of physician preference. It may be done in children under 6 months of age (especially boys), and may be necessary for older children according to circumstances. MCU should not be arranged from the Emergency Dept. and discussion of the pros and cons of this with the parents can be undertaken at outpatient review.

Follow up

Refer all children with proven UTI for follow up in the General Paediatric Clinic, or by the child's own paediatrician.

Specimens

Urine bag

Useful for collecting urine for screening purposes in children who cannot void on request (approx. 0-3 years). Wash genitalia with water and dry before application of the bag. Test urine with a dipstick for leucocytes and nitrites. If positive for either, obtain definitive specimen by SPA (or CSU if SPA fails). If clinical suspicion is high, send definitive specimen for culture regardless of dipstick result. A negative dipstick result does not exclude a UTI. Do not send bag specimens for culture in acute presentations. Antibiotics should not be given unless a definitive urine specimen has been obtained.

Supra-pubic aspiration (SPA)

For children too young to obtain an MSU, and with a high probability of UTI, or who are unwell warranting more invasive investigation.

Click here to learn how to do an SPA, including the use of bedside ultrasound

Always send for culture

Any growth from SPA urine usually indicates infection (but note possible contamination by skin commensals or faecal flora may produce a mixed growth).

Catheter Specimens

Useful after failed attempt at SPA. SPA remains the preferred method. Always send for culture. Discard first few drops of urine. Any growth >103CFU/litre indicates infection.

Midstream urine (MSU)

Can be obtained from children who can void on request. Wash genitalia with water and dry. The first few mls to be voided are not collected then a specimen is obtained. A pure growth of > 108 CFU/litre indicates infection. A pure growth > 105 may indicate early infection and requires a repeat specimen.

Dipstick Urine Test

Dipsticks can detect urinary protein, blood, nitrites (produced by bacterial reduction of urinary nitrate), and leucocyte esterase (an enzyme present in white blood cells).

They are a screening test only. If you really suspect UTI - send a specimen for micro and culture.

Remember

Blood and protein are unreliable markers of UTI Not all organisms produce nitrites and nitrites take time to develop in urine and so have poor

sensitivity. They may appear in other infections. Not all patients with UTI have pyuria. Leucocyte esterase can only be detected with relatively

high WBC counts in urine. So the test has low sensitivity. Leucocytes from local sources (vagina, foreskin) may contaminate urine. Leucocytes appear

in the urine in many other febrile illnesses eg URTI, pneumonia, etc. So the specificity is low. Overall combined sensitivity for both nitrites & leucocytes is around 50%. i.e.

Dipsticks may miss a significant proportion of infections. Always send the specimen for culture if UTI is suspected.

Urinary tract infection (UTI)

A urinary tract infection is an infection in the urine. It may affect the bladder and sometimes the kidneys. UTI is quite common, particularly in young children who are still in nappies. It can also occur in older children. It is usually caused when germs from the poo, which are on the skin, get into the urethra (the tube from which urine passes out of the bladder). This can happen to any baby and is not due to poor washing or changing.

Testing your child’s urine is the only way to know for sure if they have a UTI. Older children can get their urine from a ‘clean catch’. This is done by collecting part of the urine flow as your child passes urine into the toilet. In younger children urine is usually collected directly from the bladder. It can be done either with a needle through the stomach into the bladder (bladder tap), or through a catheter tube passed up the urethra. Although urine can be collected in babies using an adhesive bag, these are not suitable for diagnosis of UTI as they are often contaminated by germs from the skin.

Urine specimens are first usually tested with a dipstick. This can provide clues to the presence or absence of UTI, but a final diagnosis can only be made by sending the urine to the laboratory for culture. Culture results may take 24 to 48 hours.

If the dipstick test suggests a UTI, then treatment may be started. The diagnosis and treatment may be changed once the culture results are available from the laboratory. You may be asked to call to discuss the results and treatment in 1-2 days. See factsheet: Urine tests.

Signs and symptoms

Pain on doing wee. Frequently passing urine. Passing urine before getting to the toilet (incontinence or wetting). Pain in the lower part of the stomach. Smelly urine. Fever.

In young children UTI may cause a fever or general unwellness without any of the above symptoms.

Tests

Tests are usually done to look for a problem with the bladder or kidneys. Most children will have an ultrasound scan. This is a simple and painless test much like the scans that some women have during pregnancy.

In some children, a Micturating Cysto-Urethrogram (MCU) is done. This test involves putting a catheter into the bladder through the urethra. Dye is injected through the catheter and X-Ray pictures are taken. Some children find it unpleasant and frightening and may need sedation. The test is done mainly to look for a condition known as urinary reflux (sometimes called VUR). Discuss the test with your doctor.

There are other tests that are needed in a small number of patients. Your doctor will discuss these with you.

Treatment

Antibiotics are the main treatment. They can be taken by mouth. Young infants, or children who are very unwell with a UTI, should be admitted to hospital for antibiotics directly into a vein by intravenous therapy (IVT).

Care at home

Your doctor may recommend that your child stays on a low dose of antibiotic to try and prevent another UTI. This is often suggested for children who are still in nappies or who have had frequent UTI’s.

It is possible that your child might get another UTI even if your child is on a low dose of antibiotics.

You should take your child to a doctor immediately for a urine test if your child:

1. Develops any symptoms that might suggest another UTI (see above). 2. Is unwell with a fever without another obvious cause.

Follow up

Most children with UTI make a good recovery and have no future problems. In a very small number of children, there may be kidney problems or high blood pressure. Your doctor will discuss the necessary tests and how to monitor for this.

It is sensible for anyone who has had a UTI in the past to have a check on their blood pressure and a urine test every year, once they reach adolescence.

It is important that any pregnant woman who has had a UTI in the past mention this fact to her obstetrician.

For more information

Urine tests

A urine test is the only way to know for sure if your child has a urine infection. Urine infections cause children to have high temperatures and become unwell. Sometimes they can make children seriously ill, especially babies and young children.

Urine infections cannot be diagnosed with urine from a bag specimen. It is important that the urine is obtained from your child in a germ-free (sterile) way. If your child has a urine infection they may need other tests and treatment[i1] . See factsheet: Urinary tract infection.

What ways can you get urine?

Babies and small children can't wee into a pot when asked. There are four possible ways to get urine in babies:

1. Bag specimen A bag is stuck to the skin inside the nappy to catch urine. This is easy, but sometimes the bag leaks and it takes several attempts to get some wee. The other problem is that germs from the skin may get into the urine. This makes it look like your child has an infection even if they don't really.

2. "Clean-catch" A parent tries to catch some urine when the baby does a wee. It is very hard to know when a baby is going to wee, and it can be hard to catch the wee. Germs from the skin can still get into the urine.

3. Catheter A tube is put into the bladder through the urethra (the hole where the urine comes out). This is a better test, but sometimes germs from the skin may still get into the tube when it is being put in. Babies may cry when they are being held still for the test.

4. Supra-pubic aspirate (SPA) A doctor puts a needle through the skin of the lower stomach. The needle goes into the bladder and the doctor can get urine out. Germs from the skin can't get into the urine. The test needs a needle and can hurt. The doctor may not be able to get urine, if the bladder is not very full. SPA is the "cleanest", and the best test for working out if your child has a urine infection. See factsheet: Suprapubic aspirate.

Older children who can wee when asked can collect a midstream urine (MSU) specimen. This is done by collecting part of the urine flow as your child passes urine into the toilet. The urine should be collected half way through going to the toilet.

Key points to remember

Urine infections can be serious in babies and children. A urine test is the only way to know for sure if your child has a urine infection. If your child has a urine infection they may need other tests and treatment.

Suprapubic Aspirate (SPA)

Suprapubic aspirates are sometimes also called ‘bladder taps’ or ‘SPAs'. It involves getting urine directly from the bladder to look for infection (germs).SPA’s are a very safe test and problems are rare. They are usually done in younger children.

Your child lies down on his or her back and needs to be held still. A doctor puts a needle through the skin of the lower stomach. The needle goes into the bladder and the doctor can get urine out. It is the best way to get urine from babies and small children to look for infection.

What other ways can you get urine?

Babies and small children can’t wee into a pot when asked. There are other ways to collect urine although they are not suitable to determine if your child has an infection or not. See factsheet: Urine tests.

Bag specimen. A bag is stuck to the skin inside the nappy to catch urine. "Clean-catch". A parent tries to catch some urine when the baby does a wee. Catheter. A tube is put into the bladder through the urethra (the hole where the urine comes

out).

SPA is the "cleanest" and the best test for working out if a child really has a urine infection. If your child has a urine infection they may need other tests and treatment . See factsheet: Urine infections.

Does an SPA always work?

If your baby or child’s bladder is not full, the doctor may not be able to get any urine with an SPA. Sometimes we can do an ultrasound of the bladder to help work out if there is enough urine inside before an SPA is done.

If we can’t get any urine with an SPA we can either wait a little while and try again, or do a catheter.

Does an SPA hurt?

With an SPA your baby has a needle through the skin, and this hurts about as much as a blood test. SPAs are usually very quick. Sometimes we can help numb the skin with some cream (but this takes 45 minutes to work).

Are there any risks?

SPAs are a very safe test and problems are rare. Sometimes you may see a little blood in the urine for a day or so. The risk of any damage to the bowel from the needle is extremely small.

Care at home

There is no special care after the test. Your baby can be bathed normally.

Key points to remember

SPAs are the best way to get urine from babies and small children to look for infection. They are a very safe test and problems are rare. There are other ways to collect urine although they are not suitable to determine if your child

has an infection or not.

Radiology Guidelines in Emergency

Upper Airway Chest Xray Limb Xrays Abdominal X Rays (AXR) Intracranial And Skull Imaging Spinal Xrays

Upper Airway

Acute Epiglotitis/Croup: the diagnosis is made clinically NOT radiologically. Inhaled Foreign Body: If not obstructed, likely that FB has passed into intrathoracic airways.

RARELY, if sharp and may have perforated, imaging may be indicated. Retropharyngeal Abscess: look for widened prevertebral shadow (normal prevertebral width

equal to vertebral body width at C4 level).

Chest Xray

Respiratory Indications:

Suspected Lower Respiratory Tract Infection.

Inhaled foreign body - most lodge in intrathoracic tracheobronchial tree. Need films in full inspiration and expiration to demonstrate air trapping or collapse.

Chest trauma - Rib views seldom indicated. Xray to look for air leak, haemothorax or wide mediastinum.

Pneumothorax - Full inspiratory films adequate. Asthma - little information gained from xrays. Consider if:

diagnosis unclear SEVERE attack - not responding to standard therapy possible air leak. NB. Focal signs +/- fever are most likely due to mucus plug and viral illness rather

than pneumonia.

CXR NOT to be done routinely pre-operatively at any age.

Cardiac Indications

Clinical cardiomegaly or heart failure.

Remember: Large thymic shadow is normal under the age of 2 years. Heart size normal cardio-thoracic ratio 0.5 ( infants up to 0.6 ) need ECHO to detect presence of pericardial fluid.

Heart murmurs - If careful examination suggests innocent murmur - there is no need for urgent CXR in the Emergency Department - but arrange appropriate follow up.

Hypertension - CXR is seldom useful.

Limb Xrays

"Fast-Tracking" x-rays via triage assessment: these should be ordered after medical assessment of injured limb to determine the most approprate views and avoid unecessary x-ray of entire limb.

Comparative and Stress Views These are rarely necessary and should not be routinely taken. They may be useful to elucidate complex #’s (after orthopaedic consultation) if standard films are unclear.

Specific Indications/Contraindications

Trauma X Ray if signs and symptoms suggest bone injury (pain, tenderness, swelling,

ecchymosis, limitation of movement, pain on weight-bearing, refusal to use arm (unless clearly a pulled elbow), crepitus and limb deformity. If none of the above - XR is not justified.

Follow up films after reduction of a displaced # should be done to assess position. In cases of trauma with clinical impression of a fracture, but a normal XR - may

require Bone Scan to confirm diagnosis.( eg. stress # or toddler #) Pulled Elbow

If mechanism of injury and examination suggest subluxation of the radial head then XR is unneccesary.

Non accidental injury (to be seen by registrar or consultant ) Complete Skeletal Survey if child < 2yr to determine type, number and age of

fractures. If child > 2yr it should be limited to sites of clinically suspected injury. ± Bone Scan (if < 2yr) - can complement bone survey to demonstrate other #’s not

previously demonstrated. Suspect NAI if:

metaphyseal # marked or unusual epiphyseal separation # of spine or ribs unexplained skull # ± intra cranial injury

Osteomyelitis Early XR often shows no bony abnormality but may have deep soft tissue swelling.

Bone scan will demonstrate an abnormality earlier than XR. Septic Arthritis

Normal XR ( ± bone scan ) does not exclude septic arthritis. Ultrasound may be useful to demonstrate a joint effusion and soft tissue abnormality.

Metabolic disorders eg. rickets - XR of one forearm and wrist is most useful.

Abdominal X Rays (AXR)

Indicated for: Suspected bowel obstruction perforation intussusception

Foreign Bodies Ingested opaque FB require a single survey AP film that includes entire GIT- to

establish that object has passed through the oesophagus. Routine follow-up films NOT indicated unless clinical symptoms develop. ( see Ingested Foreign Body protocol)

Unecessary AXRs If unsure whether AXR would be helpful - ask consultant or registrar for advice AXR not indicated for:

Vague central abdominal pain. Gastroenteritis. Haematemesis. Pyloric stenosis. Uncomplicated appendicitis. AXR generally not indicated for - chronic constipation. ( in the Emerg. Dept setting ) - encopresis or enuresis.

Urinary Tract Imaging Bacteriologically proven UTI usually requires abdominal US +/- MCU (see Urinary

Tract Infection protocol). Suspected Abdominal Mass

Initial investigation - plain AXR and ultrasound, then further as indicated - IVP, CT scan

Blunt Abdominal Trauma Need early assessment by General Surgery to direct imaging as indicated.

Intracranial And Skull Imaging

Head Trauma Skull X-ray (SXR) is a poor indicator of intracranial injury and with few exceptions has

little to offer in the management of head injury in infants and children. Children with clinical findings of only mild head trauma do not have a statistically increased risk of intracranial injury.

Indications for SXR NAI ( more sensitive than Bone Scan ) Depressed fractures Penetrating injury Large boggy vault hematoma

CT scan - ( after neurosurgical consultation ) - useful for rapid diagnosis of suspected intracranial injuries and is the the preferred investigation if clinical evidence of intracranial injury eg. -in abnormal / deteriorating conscious state. Clinical deterioration is usually an indication for repeat CT examination.

Headaches Clinical evaluation is the most important factor in determining the need for imaging.

SXR rarely gives useful information. CT scan indications

Abnormal neurological signs. Unexplained decrease in visual acuity. Headaches with seizures. Marked change in behaviour. Enlarging head. Symptoms of raised intracranial pressure. Increasing frequency of unexplained headaches.

Afebrile Seizures Plain SXR is not indicated. CT scan indications

Persistant abnormal neurological signs/impaired consc.state. Focal EEG findings. Failure to respond to anticonvulsant therapy. Neurocutaneous lesions.

Abnormal Size / Shape Of Skull Clinical examination is usually sufficient to diagnose abnormality of the skull. Large head - rapidly enlarging head needs imaging-US or CT scan. Small head - nearly always pathological secondary to abnormal brain growth.

Evaluate with CT scan as an outpatient procedure. Premature Craniosynostosis - results in abnormal skull shape. Initial investigation - SXR to evaluate sutures. ( consult with neurosurgery )

Spinal Xrays

Trauma Indication for XR:

High force of injury Specific neck pain OR bony tenderness of spinous process(es) Altered conscious state following trauma.

Cervical Spine: Need to include 3 views: AP, lateral, odontoid Note:

> 12 yr - usually lower spine C4-7 injuries < 12 yr - usually upper spine C1-3 injuries (see also Cervical spine Guideline)

Unconscious trauma patient: Immediate lateral view of whole Cx spine ( in hard collar) will demonstrate ~ 95%

injuries. AP film will detect the remainder. If doubt consider CT scan. If neurologically normal consult orthopaedics. If neurological signs present consult neurosurgery.

NB. Down Syndrome children have increased risk of C1-2 instability. Thoraco-Lumbar Spine

Children will localise the level of the injury poorly, therefore imaging the full length of thoraco-lumbar spine may be necessary. If neurological signs present do a CT scan.

Emergency Restraint

Jump to Procedure

Principles

Physical restraint and emergency sedation should only be used when other reasonable methods of calming the patient down are unsuccessful. If a patient who is acting out does not need acute medical or psychiatric care s/he should be discharged from the hospital rather than restrained.

When restraint is required a coordinated team approach is essential, with roles clearly defined and swift action taken.

Unless contraindicated, sedation should usually accompany physical restraint.

Indications

Aggressive and combative behaviour in a patient who requires urgent medical or psychiatric care, which is:

compromising the provision of urgent medical treatment (physical or psychiatric); placing the patient at risk of self-harm; or placing staff at risk.

Alternative means of calming a patient

Crisis prevention. Anticipate and identify early irritable behaviour (+ past history). Involve mental health early for assistance (intake worker; after hours - on-call psychiatry registrar).

Provide a safe "containing" environment. This includes a confident reassuring approach by staff without added stimuli.

Listen and talk. Offer planned "collaborative" sedation (eg oral)

Contra-indications to physical restraint and emergency sedation

Safe containment possible via alternative means Inadequate personnel/setting/equipment Situation judged as too dangerous eg. patient has a weapon. Known adverse reaction to drugs usually used (eg neuroleptic malignant syndrome)

Note: If staff do not think they will be able to safely restrain the patient or manage the threat, then the Police should be called.

Procedure

1. Establish roles, including defining person in charge (usually attending doctor). 2. Assemble team. Person in charge to assemble team of 7 people.

Staff generally to be drawn from: ED (eg 2 doctors, 2 nurses), 3E (1 nurse, adolescent unit registrar), PSAs (1-2), and security (1-2).

3. Draw up drugs. Drugs of preference are midazolam 5 mg, and haloperidol 5mg (draw up together). Ensure benztropine available.

4. Secure the patient quickly and calmly. At least 5 people are required - one for the head, and one for each limb. Roles must be assigned before approaching the patient.

5. The patient should be prone, with hands and feet held flexed behind back. 6. Administer midazolam 5 mg (onset rapid) and haloperidol 5mg (onset 15-20 minutes) by

intramuscular injection into lateral thigh. Beware the risk of needle-stick injury. Further titrated doses of 0.1 mg/kg may be required (preferably iv).

7. Sedated patients must have continuous O2 saturation monitoring. They must have a nurse present continuously, with close observation of conscious state, respiration, HR, BP, and temperature.

Complications of emergency sedation include:

anaphylactic reactions respiratory depression cardiovascular - hypotension, tachycardia. extrapyramidal reactions (dystonia) may occur with major tranquillizers, particularly as the

benzodiazepine is wearing off. These is treated with benztropine (0.02mg/kg IV or IM) or repeated small doses of diazepam.

Explain

Explain the procedure to the parents/carers if possible.

Disposition

Following restraint the patient must have a complete medical and mental health assessment to guide subsequent management.

In some cases certification and transfer to an in-patient mental health facility may be required (Section 9 of the Mental Health Act 1986).

Consider the need for on-going physical restraint. Consider the need for on-going sedation.

Document

Document fully in the patient's unit record:

the indication for chemical + physical restraint. patient's response to sedation on-going observations Incident report - extremely helpful in auditing these events

Debriefing.

The need to restrain an aggressive patient is fortunately a rare event, but can be extremely distressing for staff involved. A formal debriefing session should be arranged, ideally chaired by an objective facilitator who was not involved in the restraint process.

Resuscitation

RCH Medical Emergency Team (MET) - call criteria

Emergency Drug & Fluid Calculator

Management of VT/VF or asystole/PEA (Algorithm)

ID badge size Resuscitation Card

Click to see full size algorithm

Cardiorespiratory Arrest

Signs of shock, cyanosis, bradycaradia / tachycardia, apnoea or increasing tachypnoea are warning signs and an indication for urgent resuscitation. See MET call criteria

The majority of arrests in children are due to hypoxia, hypotension and acidosis. The most common dysrhythmias are severe bradycardia, pulseless electrical activity or asystole. Ventricular arrhythmias (Ventricular fibrillation (VF) and pulseless ventricular tachycardia (VT)) are seen with pre-existing cardiac disease (cardiomyopathies, hereditary prolongation of QT interval, congenital heart disease), poisoning (eg. tricyclic antidepressants) and low voltage electrocution (less than 1000 volts), and may occur during resuscitation. SVT may cause shock in newborn infants.

Initial Management

Assessment and Management of the airway and breathing are the initial priorities.

Call for help

Dial 777 for MET call

Stimulate and assess response

Airway opening manoeuvers

Check breathing

Bag valve mask ventilation

Assess for pulse and signs of circulation

Assessment

A - Airway

Position the head - neutral position (<1 year old), or sniffing position ( 1 year of age) Open airway - Head tilt and chin lift, or jaw thrust Use oropharyngeal airway if required.

B - Breathing

Signs of respiratory inadequacy

If respiration is adequate, administer oxygen by facemask at 10 l/min. Do not use self-inflating bags in spontaneously ventilating patients.They are designed to deliver O2 only if squeezed.

If the child is not breathing, commence artificial ventilation.

Artificial Ventilation

Select the appropriate sized resuscitator bag Infant up to 2 years - 500 ml bag Child/adult > 2 years - 2 litre bag

Select an appropriate sized mask. Obtain an airtight seal O2 flow rate of 10-15 l/min and attachment of a reservoir assembly will give nearly 100% O2. An oropharyngeal airway will facilitate maintenance of the airway and bag and mask

ventilation. Brief suction of the mouth and pharynx if needed, using a yankeur sucker under direct vision Ventilate to have normal chest rise and fall. Do not over ventilate Intubation should only be attempted by those credentialed and skilled to do so

Endotracheal Intubation

Select the correct tube size:

Age Weight (kg) Tube size (mm) Length at lip (cm)

Newborn 3.5 3.0 8.5

2 months 5 3.5 9

6 months 8 4.0 10

1 year 10 4.0 11 Older than 1 year: Tube size (mm) = (age in yr/4) + 4 Length at lip (cm) = (age in yr/2) + 12

C - Circulation

If there are no signs of circulation, i.e. no pulse, slow pulse (<60) or you are not sure, commence external cardiac compression, and determine the cardiac rhythm - display the ECG

Signs of circulatory inadequacy

External cardiac compression

DO NOT interrupt except for defibrillation. Place the child on a firm surface. If on a bed, place the cardiac massage board under the

patient, not under the mattress Apply massage to the lower half of the sternum in all patients including newborns Compress sternum 1/3 the depth of the chest. Use the hand technique that allows you to achieve this - see examples pictures:

With large children use the "heel" of one hand with the other superimposed. For small children use the heel of one hand For infants use two fingers. For newborn infants the best technique is a two-handed hold in which both thumbs

compress the sternum. Gain IV or IO access as soon as possible - at least the second dose of adrenaline should be

given via this route Frequent changes of personnel (every few minutes) is desirable During resuscitation do not stop to check for a pulse unless the ECG shows an organised

rhythm. After DC shock continue CPR for 2 minutes prior to checking rhythm.

Resuscitation algorithm

Click to see full size algorithm

During resuscitation

Correct treatable causes

Hypoxaemia Hypovolaemia Hypo/hyperthermia Hypo/hyperkalaemia Tamponade Tension pneumothorax Toxins/poisons/drugs Thrombosis

Other drugs to consider

Atropine for persistent asystole / bradycardia (20mcg/kg) (min 100mcg, max 600mcg)

Lignocaine Never give lignocaine after Amiodarone Amiodarone is the preferred agent Same indications as Amiodarone. Dose (1mg/kg) (0.1ml/kg of 1%)

Magnesium Sulphate For hypomagnesaemia or for polymorphic VT (torsade de pointes) 50% solution: 0.05-0.1ml/kg (0.1-0.2mmol/kg) (max 2 g) Infuse over 5 mins.

Sodium bicarbonate, calcium, and doses of adrenaline >10mcg/kg/dose have no place in routine resuscitation.

Other issues

Blood gas analysis

It is not a priority in initial resuscitation attempts, and obtaining a sample should not distract from other resuscitation manoevres.

Arterial (and to some extent venous) blood gas analysis can help determine degree of hypoxaemia, adequacy of ventilation, degree of acidosis, and presence of electrolyte abnormalities such as hyopmagnesaemia.

Post resuscitation care

Ensure airway and breathing are managed effectively including intubation if not already performed. Do not extubate. Use adequate sedation and analgesia.

Ventilate to normo carbia Circulation - maintain adequate blood pressure with use of inotropes as needed. Monitor for

further arrhythmias. Aim for core temperature of 35 degrees (do not actively warm if core temp >32 degrees)

Ongoing anti arrhythmic Ensure normo glycaemia

Salicylates Posioning

See also General Management of Acute Poisoning Guideline

Examples: Aspirin and aspirin containing drug compounds Oil of Wintergreen Dencorub

Assessment

Symptoms Tinnitus, vomiting, hyperventilation, lethargy, coma, seizures, hyperthermia, dehydration, hypoglycaemia, non cardiogenic pulmonary oedema

Initial respiratory alkalosis (may be transient), followed by paradoxical aciduria (pH <6), then metabolic acidosis & hypokalaemia (± ongoing respiratory alkalosis).

Patients Requiring Treatment

Acute ingestion 150mg/kg All symptomatic patients Ingestion of unknown quantity

Investigations

Serum salicylate level at presentation (on patients requiring treatment), and 2 hrly if symptomatic or enteric coated preparation. (Need to call the RCH lab to get test run urgently as it is sent to RMH for analysis)

Urea & electrolytes, creatinine, acid-base, glucose.

Management

a. Asymptomatic o Charcoal 1g/kg (if <1 hour since ingestion unless enteric coated preparation) o Observe 6 hours & discharge if still asymptomatic o If enteric coated preparations, serial salicylate levels (2 hourly) o Admit if levels have not plateaued at 6 hours post ingestion o I.V. bicarbonate infusion 1mmol/kg/hr to correct any acidosis (pH <7.3)

b. Symptomatic o All symptomatic patients require urgent medical assessment and investigations as

above. o Charcoal 1g/kg unless altered conscious state (protect airway first)

o I.V. fluid resuscitation to correct dehydration (use N. Saline) o I.V. bicarbonate infusion 1mmol/kg/hr, after initial slow bolus of 2mmol/kg, (keep

urine pH >7.5) o Potassium replacement as required o Worsening symptoms, convulsion, coma, contact I.C.U. (5212) for respiratory

support ± haemodialysis o Salicylate level >7mmol/l following an acute poisoning contact I.C.U. for consideration

of haemodialysis.

Septic Shock

Emergency Drug & Fluid Calculator

Ward Management of Early Septic Shock

1. Any child at risk of sepsis and septic shock should be reviewed by the Unit Registrar 2. Failure to respond to initial fluid resuscitation should be considered an indication for

immediate referral to Intensive Care 3. If nursing staff on the ward are unable to obtain a medical registrar quickly they should

contact ICU directly

Does this child have early septic shock?

Features of circulatory and respiratory insufficiency are

1. Tachycardia 2. Tachypnoea and or desaturation in air 3. Increasing Systolic to Diastolic difference 4. Poor peripheral perfusion (cold extremities with prolonged

capillary refill) 5. Alteration in conscious state eg confusion 6. Metabolic acidosis - do not attempt to do an arterial blood

gas in thrombocytopaenic patient without discussion with the Unit Registrar

If a child has suspected sepsis with features of circulatory or respiratory insufficiency, give OXYGEN 8 L/min via face mask and monitor saturation with a pulse oximeter

If there is no IV access, put in an IV (contact ICU if any difficulty) Give a BOLUS of 20 ml/kg NORMAL SALINE intravenously A second bolus of 20 ml/kg may be given if there is no improvement in heart rate or perfusion

in 10 MINUTES If the signs of circulatory or respiratory insufficiency resolve with 20-40 mlkg of saline - continue to monitor the child closely on the ward

If they do not resolve refer the child to intensive care (Ext 5211) Sickle Cell Disease Guideline

Sickle cell disease is caused by structurally abnormal haemoglobin (Hb S) that causes a rigid distorted red blood cell (sickle cell). There are 3 common types

sickle cell anaemia (SS disease) is the most common sickle ß Thalassemia sickle haemoglobin C disease

Acute crises may occur spontaneously or precipitated by

1. Infection 2. Dehydration 3. Hypoxia 4. Sedatives and local anaesthetics

At some stage in early childhood, patients become functionally asplenic and thus at risk for infection particularly by encapsulated organisms (e.g. pneumococcus). Patients are generally on penicillin prophylaxis and folate supplements, and have had pneumococcal polysaccharide vaccine.

Some patients are now on hydroxyurea to prevent sickling crises. These patients may develop neutropenia, which increases their risk of sepsis. Some patients may have a degree of cardiomyopathy; thus fluid resuscitation should be used with caution, and signs of fluid overload looked for closely.

Patients with sickle cell disease may present with the following problems

Fever Vaso-occlusive crisis Acute chest syndrome Acute splenic sequestration Aplastic crisis Stroke Priapism

Many of these presentations require urgent treatment, and discussion with the Haematology Consultant on-call is mandatory.

Fever & sickle cell disease

Background

Patients are functionally asplenic and thus at greater risk for invasive disease particularly by encapsulated organisms (e.g. pneumococcus).

Assessment

If pain is also present, then treat as Vaso-occlusive disease first Cough, dyspnoea looking for signs of acute chest syndrome Look for other sites of infection (e.g. osteomyelitis) Check Immunisation status, penicillin prophylaxis, use of hydroxyurea

Assess: Degree of pallor Evidence of systemic or local infection Evidence of shock (poor capillary refill, tachycardia, hypotension etc) Spleen size (compared to baseline)

Management

1. Give high flow oxygen 2. Obtain FBE (including reticulocyte count) 3. Obtain blood culture. Urine culture and culture other sites, as indicated. 4. Obtain chest X-ray if respiratory signs or symptoms, or high fever with no focus of infection 5. Consider parenteral antibiotic(s) (flucloxacillin 50mg/kg 6 hourly + gentamicin 7.5mg/kg

(6mg/kg if >10yrs) daily; do not delay for FBE or urine culture results 6. Consult on-call Haematology Consultant 7. All children with fever > 38.5 degrees should be admitted

Painful Vaso-Occlusive Crisis

Background

All episodes of pain should be treated initially as vaso-occlusive disease. Other diagnoses may need to be considered later. Pain may be limb, back, chest (see specific guideline) or abdominal. NB Chest pain should be treated as an acute chest syndrome and not simply as a vaso-occlusive disorder.

Assessment

Usually present as bone pain (e.g. arm or leg pain) but maybe back or abdominal pain. Most patients will be able to tell you this is pain similar to previous episodes. Formal pain scale should be used to quantify their degree of pain.

Is there associated fever or dehydration? What analgesics have already been given (home or other hospital)? What analgesics do the patient or family feel are required for this episode? Consider other aetiologies after treating for pain (e.g. cholecystitis, appendicitis, osteomyelitis)

Management

Start analgesics promptly to provide effective relief of pain.

Mild pain

Paracetamol (20mg/kg) + codeine (1mg/kg) Push oral fluids If not settling then add ibuprofen 10mg/kg If still not settling then move to severe pain

Moderate to severe pain

Give high flow oxygen.

Take blood for FBE, Reticulocyte count, cross match and bilirubin. Give bolus of 10-20mls/kg of 0.9% (Normal) Saline followed by maintenance rate (including

oral intake) of 5% Dextrose & 0.45% (1/2 Normal) Saline. Patients with cardiomyopathy will require less fluid.

Recommended analgesics: Morphine 0.05 mg/kg/dose IV. Repeat as necessary (see analgesia and sedation

guideline) Some patients may require higher individual doses, based on prior history or may

benefit from continuous infusion via PCA (Patient Controlled Analgesia). May need blood transfusion using WBC filtered blood Discuss with Haematologist on call

Acute Chest Syndrome

Background

Sickle cell disease can produce an acute illness related to infarction of the lung tissue. Usually associated with lower respiratory symptoms, hypoxaemia and a new infiltrate on CXR. Chest pain and hypoxaemia may be the only signs. Chest pain should be treated as an acute chest syndrome and not simply as a vaso-occlusive disorder.

NB This is a life threatening illness and patients may deteriorate quickly

Assessment

Patients should have respiratory rate, oximetry and temperature documented on arrival. Degree of pain should be quantified on an appropriate pain scale Hypoventilation is common due to pain.

Management

1. Give high flow oxygen 2. Maintain and treat airway, breathing and circulation problems first 3. Maintain hydration with IV + oral intake at maintenance rate 4. Treat pain aggressively by giving adequate analgesia to control pain (see VOC guideline) 5. Obtain chest xray 6. All patients with chest pain should be admitted, irrespective of CXR findings 7. Cross match for possible exchange or simple transfusion 8. Consider broad-spectrum antibiotics (see fever and sickle cell guideline) 9. Consult Haematology urgently and prior to transfusion or admission

Acute Splenic Sequestration

Background

This is defined as a haemoglobin drop of at least 20gm/l below patient’s baseline level with an acutely enlarged spleen. Mild to moderate thrombocytopenia is often present. Reticulocyte count is equal to or greater than patient’s usual baseline. Consider co-existent aplastic anaemia if reticulocyte count is low. Most common in infants and young children. It has a high mortality rate

Assessment

Clinical presentation

pallor lethargy hypotension increased splenic size

Management

1. Investigations o Cross match o FBE including platelet count o Reticulocyte count o Blood and urine cultures if febrile; CXR if febrile and respiratory symptoms

2. While waiting for blood, give 0.9% Saline to treat hypovolaemia. (10-20ml/kg) NB careful in patients who have pre-existing cardiomyopathy

3. Suggest initial transfusion of 10 ml/kg of packed red cells for patients with haemoglobin <50gm/l or signs of shock.

4. Do not raise Hb above baseline, since the spleen will shrink and autotransfusion will occur. This will result in an increase in the percentage of HbS and risk of stroke (due to hyperviscosity)

5. Treat with antibiotics if febrile (see fever & sickle cell), and analgesics for pain (see vaso-occlusive disease)

Aplastic Crisis & Sickle Cell Disease

Background

Acute illness associated with Hb below baseline for that patient and associated with a substantially decreased reticulocyte count (usually <1%). Usually associated with acute infection in particular parvovirus. May be associated with enlarged spleen as well (see sequestration)

Assessment

Patients present with onset of pallor over a few days, tiredness and lethargy. May be associated with fever

Management

1. Give high flow oxygen 2. Maintain and treat airway, breathing and circulation problems first 3. IV + oral fluids at maintenance rates – do not add potassium to i.v. fluid

4. Transfuse patient if symptomatic anaemia or Hb < 50gm/l (usually 5ml/kg over 4 hrs). The blood product used should be WBC filtered and, if the patient is on hydroxyurea should be irradiated also. Close observation for fluid overload. Transfusion may need to be repeated.

5. Treat fever and pain as required (see fever and VOC guidelines) 6. Discuss with on-call Haematologist

Stroke & Sickle Cell Disease

Background

Acute neurological events occur in about 10% of patients with Hb SS. These can present as

hemiparesis monoparesis aphasia or dysphasia seizures cranial nerve palsies coma

Can occur suddenly or as a complication of acute chest syndrome or aplastic crisis NB. Consider other causes as well (see coma and seizure guidelines)

Assessment

Document the neurological examination, noting previous deficits Assess

temperature (see fever & sickle cell guideline) Glucose level Level of consciousness (AVPU or GCS)

Management

1. Give high flow oxygen 2. Maintain and treat airway, breathing and circulation problems first 3. Investigations:

o FBE o Cross match

4. Arrange for partial exchange transfusion but remember not to over transfuse (e.g. Hb < 100gm/l)

5. Obtain CT without contrast. CT scan is to exclude intracranial haemorrhage 6. Notify on-call Haematologist urgently. 7. May need admission to ICU for immediate exchange transfusion

Priapism & Sickle Cell Disease

Background

Priapism is prolonged painful erection of the penis often starting in the early hours of the morning. Occurs in 2 forms (a) stuttering episodes which last 2-4 hrs but are often recurrent and may precede a severe episode (b) severe attack lasting longer than 4 hrs and can result in impotence. Recurrent episodes should be evaluated by haematology in outpatients.

Assessment

Length of current episode Associated symptoms – fever, dysuria, dehydration or pain at other locations. History of prior episodes and the previous treatments and effectiveness Symptoms of obstructive sleep apnoea.

Investigations (should not wait for results before treating patient)

Check FBE and reticulocyte count Cross match Cultures and CXR as required

Management

1. Administer intravenous fluids at maintenance rate. 2. Give analgesia – Morphine 0.05mg/kg IV titrated to effect 3. Encourage emptying of the bladder; catheterize, if unable to empty bladder. 4. Do not use ice or ice packs 5. Consult General Surgery (Urology) and Haematology if priapism has lasted more than 3-4 hrs

(may require aspiration and drainage) 6. If no response to treatment, arrange for partial exchange transfusion. 7. Admit under Haematology Unit

Notes

Simple measures should be tried first at home, particularly if less than 3-4 hrs since onset:

Push oral fluids Analgesia Urination Moderate exercise Take a bath or shower

Smoking parents

The facts

Parent smoking is an important child and adolescent health issue. Children with a parent who smokes have a significantly increased risk of disease, hospitalisation, SIDS, and a doubled risk of that child taking up smoking themselves in adolescence.

Diseases in children associated with parent smoking include:

Croup, bronchiolitis and pneumonia in infants

Wheezing illnesses and asthma Otitis media, tonsillitis and the need for surgery for both Anaesthetic complications Serious bacterial infections such as meningococcal disease Possibly vascular phenomena such as Perthes Disease

How do smokers quit?

Quitting smoking is a process that occurs over time, not an event. Smokers rarely just stop- there are many small steps a smoker needs to go through to move from thinking about quitting to actually trying to give up. If done sensitively, brief advice from a health professional can help to move them along that path towards quitting. In the adult health setting, a doctor's routine recommendation to a smoking patient that they should quit has been shown repeatedly to lead to a small but significantly increased likelihood of smoking cessation.

What to do

1. Ask ALL parents about smoking

2. If a parent smokes, let them know you/ the hospital believes parent smoking is an important child health issue (The majority of parents who smoke expect that health professionals will address their smoking). Do this sensitively [See examples: suggested lines] so as to keep them engaged on the subject; the danger is leaving them more resolved that they will continue to smoke!!

3. If parents seem interested in quitting, give them what help you can. If you do not have the knowledge, skills and time to do much (ie. the majority of us!) refer them on to an expert. GP's and the Quitline (131 848) are the sources of help parents say they most prefer. We have a downloadable letter for the family's GP and a quickfax form for the quitline for you to use.

Positively reinforce any efforts that a parent is making towards smoking cessation (see links). Supraventricular Tachycardia (SVT)

Assessment

Symptoms

Infants - pallor, dyspnoea, poor feeding. Older children - palpitations , chest discomfort

Signs

Regular tachycardia - HR usually 180-300/min Hypotension may be present. Heart failure, especially infants.

Investigations

12 lead ECG showing regular narrow complex tachycardia.

Consult cardiology urgently if tachycardia is broad complex or irregular.

Management

Monitor with continuous ECG trace and frequent measurements of blood pressure If necessary apply oxygen 10 litres / min by face mask If child is shocked (ie. hypotensive, poor peripheral perfusion, impaired mental state) proceed

to direct current cardioversion (see below) If child is not shocked treat with intravenous adenosine

Shocked Child - Direct Current Cardioversion

Call ICU. Ensure experienced staff and full resuscitative measures are present Ensure child is on oxygen, and has intravenous access Administer diazepam intravenously if there is any chance of awareness DC revert using a synchronized shock of 1 joule/kg, An unsynchronized shock is necessary for ventricular fibrillation or polymorphic ventricular

tachycardia

Stable Child – Vagal Manoeuvers And Adenosine

Vagal manoeuvers. Valsalva if child old enough; gag or icepack/iced water for infants - apply to face for a maximum of 30 seconds. Do not use eyeball pressure.

Intravenous adenosine

Should be administered only by experienced staff. Alert ICU before use.

Insert cannulae into a large proximal peripheral vein (the cubital fossa is ideal) with three way tap attached

Draw up starting dose of adenosine 0.1 mg/kg. If necessary dilute to 1 ml with normal saline. Don't draw up the adenosine until after inserting the IV. Adenosine is expensive and in some cases IV insertion alone will lead to reversion to sinus rhythm.

Draw up 10 ml saline flush Turn on the ECG trace recorder Administer adenosine as a rapid IV push followed by the saline flush Repeat procedure at 2 minutely intervals, until tachycardia terminated, increasing the dose of

adenosine by 0.05mg/kg each time up to a maximum of 0.3 mg/kg (max dose 18mg). Perform 12 lead ECG post reversion

The recorded strip at the time of conversion to sinus rhythm should be inspected and saved, for concealed pre-excitation which may only be revealed during the first few beats after conversion to

sinus rhythm. After a patient has been reverted a 12 lead ECG should be performed to look for pre-excitation and other abnormalities.

Rapid re-initiation of tachycardia is not uncommon, mostly due to premature atrial contractions stimulated by the adenosine. If this occurs consider trying adenosine again.

Side effects including flushing and chest tightness/discomfort are not uncommon. These are usually brief and transient. Rarely atrial fibrillation or prolonged pauses may occur.

Adenosine is contra-indicated in adenosine-deaminase deficiency (rare immune deficiency) and patients taking dypyridamole (Persantin). Care is required in asthma, as it may cause brochospasm.

If these measures fail to revert the SVT consult Cardiology.

Disposition

A follow up plan should be made in consultation with cardiology.

Syncope

Definition

Brief, usually sudden loss of consciousness and muscle tone caused by cerebral ischaemia or inadequate oxygen or glucose to the brain.Features

lasts only a few seconds child limp and unresponsive tonic-clonic movements can occur with prolonged unconsciousness patient back to normal on awakening

Cause

Vasovagal (fainting) Orthostatic or postural hypotension Cardiac Structural (e.g. critical aortic stenosis, Tetralogy of Fallot, atrial myxoma etc) Arrhythmia (e.g. prolonged QT**, AV block , sick sinus syndrome) Respiratory (e.g. cough, hyperventilating, breath holding) Metabolic (e.g. anaemia, hypoglycaemia, hysteria etc)

** Long QT syndrome

Children with long QT syndrome are prone to polymorphic ventricular tachycardia (‘torsades de pointes’) that may cause syncope, seizures and sudden death. The syndrome should be suspected if events are precipitated by exercise, stress, swimming or noise. Events may also occur during sleep. It is important to take a thorough family history and to routinely obtain an ECG to look for a long QTc when investigating syncope.

It is important to diagnose long QT syndrome because the risk of death can be substantially reduced by simple treatment. Even if the child has died, the diagnosis can

often be made by genetic studies on autopsy specimens, and investigation of relatives. The condition is usually autosomal dominant.

The diagnosis cannot be excluded just because the QT interval is normal on an ECG. In addition, other “cardiac electrical myopathies” with similar symptoms may have an entirely normal ECG. If there is any reason to suspect long QT syndrome, then discuss with Cardiologist on call.

Management

Common causes are vasovagal and orthostatic hypotension. History of the surrounding events is important. Orthostatic hypotension usually occurs on standing suddenly. Vasovagal associated with environmental or emotional stresses. Structural cardiac lesion more likely if syncope is exertional. Examine patient for cardiac anomaly (e.g. murmur, heaves etc) Investigations should include an ECG - look for dysrrythmias;

short/abnormal PR interval (eg Wolff-Parkinson-White syndrome); and prolonged QT syndrome. If there is any reason to suspect long QT syndrome, then discuss with Cardiologist on call.

Click here for help with ECG interpretation If unconsciousness lasts more than a few seconds and patient not fully awake immediately

after the event then consider seizures as a cause (see table). Patient may need an EEG to clarify this issue.Hysterical syncope generally occurs in front of

an audience, patients do not hurt themselves and there is associated moaning or non rhythmical jerking.

Follow up

All patients who have unexplained syncope should be reviewed in outpatients.

Differentiating syncope from Seizures

Syncope Seizures Hypoglycaemia

Period of Unconsciousness

Usually seconds Frequently 5mins or longer

Usually over a few mins

Incontinence Absent May be present Absent

Confusion on waking

Absent Marked for 20-30 mins

Usually, slow to improve

Tonic-Clonic movements

Occasionally & brief particularly if unconsciousness is prolonged

Frequently present

Frequently absent

EEG Normal Frequently abnormal if done soon

Normal

Click to view

after event

Management of tetanus-prone wounds

The new Immunisation Schedule recommends that 10-yearly tetanus boosters are no longer required up until the age of 50, provided that the primary series of 3 vaccinations plus 2 boosters have been given.

The recommendations for the management of tetanus-prone wounds remain the same.

Types of wounds likely to favour the growth of tetanus organisms include:

compound fractures deep penetrating wounds wounds containing foreign bodies (especially wood splinters) wounds complicated by pyogenic infections wounds with extensive tissue damage (eg. contusions or burns) any wound obviously contaminated with soil, dust or horse manure (especially if topical

disinfection is delayed more than 4 hours). Re-implantation of an avulsed tooth is also a tetanus-prone event, as minimal washing and

cleaning of the tooth is conducted to increase the likelihood of successful re-implantation.

Wounds must be cleaned, disinfected and treated surgically if appropriate.

History of tetanus vaccination

Type of wound

Tetanus vaccine booster

(see below)

Tetanus immunoglobulin

< 5 years since last dose

All wounds NO NO

Clean minor wounds NO NO 5-10 years

since last dose All other

wounds YES NO

3 or more doses

> 10 years since last dose

All wounds YES NO

Clean minor wounds YES NO

< 3 doses or uncertain All other wounds YES YES

A combination vaccine should be used in order to boost community protection against pertussis:

Please note that CDT and Tetanus Toxoid vaccine are no longer available.

< 8 years old DTPa-IPV (Infanrix-IPV®) > 8 years old dTpa (Boostrix®)

Can use a diphtheria/ tetanus toxoid vaccine (ADT® ) if pertussis vaccination is contraindicated.

Theophylline Poisoning

See also General Management of Acute Poisoning Guideline

Beware, many slow release preparations may cause toxicity after many hours Beware, sudden deterioration may occur with arrhythmias or convulsions

Assessment

CNS Agitation, hyperventilation, headache, convulsions

Cardiovascular Arrhythmias

GIT nausea & vomiting (may be intractable), thirst, diarrhoea

Patients Requiring Treatment

Acute ingestion of 10mg/kg Any ingestion while on maintenance theophylline Ingestion of unknown quantity All symptomatic patients

Investigations

Theophylline levels should be determined on all patients requiring charcoal Serial levels are required at 2 hours then every 2 hours until peak reached or decline

demonstrated. If slow release preparation has been taken:

admit, continue levels at 4 hourly intervals after decline or plateau to ensure detection of secondary peak

Seizures are common at levels >330 micromol/L Haemoperfusion commonly needed at levels > 550 micromol/L. U&E, Cr and Glucose on all patients.

Management

a. Asymptomatic o Charcoal 1g/kg o Observe 4 hours. If no symptoms, discharge if not slow release medication. o If ingestion of slow release preparation, admit for observation and serial drug levels

b. Symptomatic o Charcoal 1g/kg initially unless altered conscious state (protect airway first) then

0.5g/kg 4 hourly, and whole bowel irrigation with colonic lavage solution 30ml/kg/hr. o Cardiac monitoring o I.V. fluid resuscitation & maintenance of adequate hydration is vital

o If depressed conscious state, arrhythmias or intractable vomiting contact I.C.U. (5212) as likely to need intubation

o Severe intoxication may require haemoperfusion o If agitated, may need sedation with a benzodiazepine or phenobarbitone.

Major paediatric trauma - The primary survey

Emergency Drug & Fluid Calculator

See also the secondary survey

Prior to Arrival

Ensure senior emergency medical and nursing staff are aware of all the available details. Delegate specific tasks to appropriate individuals. Notify the Intensive Care Unit registrar and the Surgical registrar on call Notify other specialist registrars as appropriate (eg. neurosurgery, orthopaedics) Notify other departments as appropriate (eg. radiology, blood bank) Check the resuscitation equipment and prepare intravenous lines and fluids If possible estimate the child’s weight using the formula (Age + 4) x 2 and calculate:

a. The amount of fluid bolus at 20 ml/kg b. The endotracheal tube size (age/ 4) + 4 c. Any other drugs likely to be needed

On Arrival

Immediately perform a primary survey by assessing and managing the child’s airway, cervical spine, breathing and circulation.

Obtain a history from the parents or ambulance officers if possible eg. type of trauma, speed of the vehicle, height of the fall, restraints or safety equipment used, whether other people were injured.

Airway and the Cervical Spine

Assess the child’s airway whilst protecting the cervical spine. The cervical spine should be immobilized initially by in-line stabilisation, followed by the rapid (gentle) application of a properly fitted hard collar, sandbags and tape (see Cervical Spine guideline)

If the airway is inadequate, apply a jaw thrust manoeuvre, clear any obstruction using suction under direct vision and consider intubation.

Breathing

Apply oxygen 10 l/min by face mask. Assess the child’s breathing by observing:

a. the work of breathing (recession, respiratory rate, accessory muscle use) b. the effectiveness of breathing (oxygen saturation, chest expansion, breath sounds) c. the effects of inadequate respiration (heart rate, mental state)

If breathing is inadequate, exclude a tension pneumothorax, use positive pressure ventilation with bag/valve/mask and consider intubation.

Insert a large oro-gastric tube to treat and prevent gastric dilatation.

Circulation

Assess the child’s circulatory state by observing a. the pulse rate, skin colour, capillary refill time, blood pressure b. the effects of an inadequate circulation (respiratory rate, mental state)

Establish intravenous access with two cannulae that are as large as practicable - ideally one situated in each cubital fossa.

If an IV cannula is unable to be sited rapidly consider the use of an intraosseous needle inserted into a non-traumatised leg.

As the IV is inserted take blood for a blood sugar, FBE, cross match and lipase. If circulation is inadequate give a fluid bolus of 20 ml/kg of normal saline. Tamponade any continuing external haemorrhage. If the circulation continues to be unstable, repeat the fluid bolus using normal saline or a

colloid solution. If a third bolus is necessary consider using whole blood and arrange early surgical intervention

Disability (Mental State)

Assess mental state by determining the child’s best response to a painful stimulus, observing their posture and examining the pupillary reflexes

The response to pain is determined by squeezing one ear lobe hard and observing the best response to that stimulus (eg. flexion of one arm and extension of legs is recorded as flexion to pain)

Note whether the child: A is alert, or V responds to voice, or P responds to pain by localizing appropriately, flexing limbs or extending limbs to

pain, or U is unresponsive.

Monitor

Respiratory rate, heart rate, blood pressure, oxygen saturation and rectal temperature. Response to pain and pupillary light reflexes

Normal Physiological Values:

Age Resp. rate (breaths per

minute)

Heart rate (beats per

minute)

Systolic blood pressure (mm Hg)

<1 year 30 – 40 110 - 160 70 – 90

2-5 years 25 – 30 95 - 140 80 – 100

5-12 years 20 – 25 80 - 120 90 – 110

>12 years 15 – 20 60 - 100 100 – 120

Temperature

Minimize hypothermia by limiting exposure of the body during examination, and by warming all ongoing fluids.

Radiology

Arrange for cervical spine, chest and pelvic X-rays. If there is NO clinical suspicion of a pelvic injury AND the child has a normal conscious state

the pelvic X-ray may be omitted. Arrange additional radiology as indicated

Secondary Survey

Click here to read details of the secondary survey

Analgesia

RCH Travel Clinic

The RCH Travel Clinic is now in full-swing! The Infectious Diseases Unit of the Department of General Medicine runs this weekly clinic.

Pre-travel advice and vaccinations are provided for children and their parents.

We are pleased to offer this service to existing and new patients of the hospital and their families. We are also happy to see hospital staff individually and their families.

A medical referral is required and all patients are bulk-billed.

Some travel vaccines are expensive and will need to be bought on the day (Wood Pharmacy offer discounts to Staff members, and reduced prices for patients as well).

For many overseas trips it is worthwhile being seen at least 6 weeks before departure to allow adequate time for the various vaccines to be given and for their effectiveness to develop.

We are also happy to see children or families who have returned from overseas and who are unwell, possibly related to travel acquired infection.

Tricyclic Overdose

See also General Management of Acute Poisoning Guideline

Assessment

Symptoms

Anticholinergic vomiting, blurred vision, ataxia, tachycardia, urinary retention

Antiadrenergic vasodilatation

Sodium Channel blockade widened QRS (>0.12 ms) QT prolongation reduced cardiac contractility & hypotension

CNS Depression

drowsiness, coma, convulsions

Symptomatic patients require urgent medical assessment

Management

Charcoal 1g/kg unless altered conscious state (protect airway first) Require ECG, cardiac monitoring Asymptomatic: observe for 6 hours post ingestion and discharge if have a normal ECG just

prior to discharge All symptomatic patients should be admitted If widened QRS on ECG commence Sodium Bicarbonate infusion 1mmol/kg/hr, after initial

slow bolus of 2mmol/kg If altered conscious state, widened QRS or arrhythmia contact I.C.U. (5212) & protect airway

Urticaria

Assessment Physical Examination Differential Diagnosis of Urticaria Investigations Management Resources

Pruritic, elevated skin lesions surrounded by erythematous base commonly described as "hives" Due to transient extravasation of plasma into the dermis. It is a common condition - 25% of individuals will have it at some stage.

Deeper subcutaneous extension is much less common and termed angioedema. It involves face (eyelids, lips, tongue), hands and feet, and sometimes other areas ( trunk, genitalia, mucous membranes ).

Acute Urticaria (<6 weeks) Chronic Urticaria (/>6 weeks)

Assessment

Explore events a few hours or days before onset of rash.

A specific cause is not identified in most of the cases (Idiopathic)

Other causes are

Medications including antibiotics like penicillin, cefaclor (5-21 days after commencing course),amoxycillin,etc

Infections include viruses and bacteria Foods are infrequent causes (may include nuts, eggs, shellfish, strawberries, tomatoes, and

cow’s milk.) Bites and stings include bees, wasps, scorpions, jelly fish and spiders. Physical triggers may include pressure, cold, exercise and rarely water.

Physical Examination:

Erythematous raised skin lesion (Wheal)

Localised or generalised Well circumscribed but often coalescent May be intensely pruritic with excoriation Vary in size from tiny flat papules to large raised plaques Flat centre with raised erythematous edge Diagnostic feature is polymorphic appearance and transience of individual lesion. Observe for dyspnoea or dysphagia the first few hours after urticaria

Anaphylaxis is a medical emergency — sudden onset of urticaria, angioedema, dyspnoea or hypotension . Treat immediately

If recurrent angioedema without wheals, think of C1 esterase inhibitor deficiency.

Blotchy rash typical of urticaria

Urticarial lesions with typical clear skin in centre. These are not "target lesions"

Differential Diagnosis of Urticaria

Erythema multiforme

How to distinguish? EM is:

Usually not itchy Does not move around - individual lesions perist for days Has target lesions with a central papuler, blister, purpura or ulcer. Often has mucosal involvement

Rare differentials

Mastocytosis Flushing Juvenile Rheumatoid Arthritis Vasculitis — Henoch Schonlein purpura Pityriasis rosea (early lesions)

Investigations

Investigations are usually not indicated for acute urticaria

Initial investigations of chronic urticaria include FBE, Differential, ESR and ANA.

Management

Remove identifiable cause if any Cool Compresses Explanation, information and reassurance Manipulation of diet is not indicated. Anti-histamines to alleviate itching Promethazine (Phenergan)

0.2-0.5mg/kg/dose (adult 10-25mg) 6-8H IV, IM or oral. Contraindicated for children less than 2 years old or Cetirizine (Zyrtec) 0.2mg/kg/dose (adult 10mg) 12-24H oral. Contraindicated for children less than 1 year old

Steroid creams do not work. For severe cases, a single dose of oral prednisolone may be considered

Indications for Specialist Referral:

associated bruising or systemic features (need to exclude urticarial vasculitis or chronic urticaria as a manifestation of another disease process)

Severe life-threatening allergy e.g. peanut or latex allergy Poor response to antihistamines Angioedema involving the airways Chronic urticaria (>6 weeks)

Hives

Hives are slightly raised patches of skin. These raised patches are called wheals. They are more red or more pale than the surrounding skin and occur in groups on any part of the body. They are often itchy, but sometimes also sting. Each wheal lasts a few hours before fading without trace. New areas may develop as old areas fade. Often the wheals join together to form larger swellings. The area of affected skin can vary in size from quite small to as large as a dinner plate.

Urticaria is the medical word for hives. Hives are very common - one out of every four people will have hives at some time in their life.

Hives will usually go away within a few days. If your child continues to have hives for more than 6 weeks this may need investigation. Treatment includes avoiding known triggers (ie things known to cause the hives) and medicines. Triggers may be different for each child.

Signs and symptoms

Symptoms of hives include:

Raised round wheals that look like mosquito bites. The wheals are red on the outside and white in the middle. They are normally very itchy. A single wheal often lasts around 24 hours. The wheals appear in batches or clusters. One batch fades away as a new batch appears. The rash may last for days or weeks.

Anaphylactic shock

Usually, the skin rash looks or feels unpleasant but is harmless. However, sometimes a more serious allergic reaction known as anaphylactic shock can happen. This is a medical emergency and an ambulance should be called immediately.

Symptoms of anaphylactic shock include:

Swelling of the tongue and throat. Breathing difficulties. Choking.

Collapse.

If your child has experienced anaphylactic reactions in the past you may be advised to have ready access to adrenaline. Your child could also wear a Medi-alert pendant or bracelet, to let other people know what may cause them to have an allergic reaction. Discuss this with your GP.

Causes

Often it's impossible to find out what triggers hives in children. Usually no tests are needed. Hives is a type of skin rash that is an allergic reaction. This means the immune system responds to a substance as if it were toxic.

Hives occur when blood plasma leaks from the blood vessels into the skin. This happens when a chemical called histamine is released.

The following can cause histamine release and hives:

Allergic reactions. Insect bites. Virus infections. Chemicals in foods and medicines.

Treatment

The best treatment for hives is to find and remove the cause or trigger. This is not always possible. For most people, each attack of hives will become more severe and intense if they are repeatedly exposed to the same trigger.

Treatment for severe or frequent hives may include:

Checking that the rash isn't caused by an underlying disorder. Avoiding known triggers in your child. Medications, such as antihistamines and corticosteroids, to reduce the immune system

response to the triggers. Avoiding things that make the rash worse - such as sunshine, heat and hot showers. Applying cool compresses (a face washer/ cloth nappy/ clean tea towel soaked in cool water)

may also help relieve the itching and stinging. Antihistamines are often prescribed for your child to provide relief from itching. These can be

very useful if taken at bedtime.

Key points to remember

Hives is a skin rash characterised by reddened and raised round wheals.

This type of skin rash is an allergic reaction, which means the immune system responds to a substance as if it were toxic.

Treatment options include avoidance of known triggers, and medications - such as antihistamines and corticosteroids.

Von Willebrand Disease (vWD)

See also: Haemophilia

Background

The most common inherited bleeding disorder affecting 0.1 - 1% of the population. Caused by a deficiency (either quantitative or functional) in von Willebrand Factor (vWF). Deficiency of vWF causes inadequate platelet adhesion and secondary deficiency of Factor VIII. Affects males and females equally.

Characterised by easy bruising, bleeding from mucous membranes (particularly epistaxis, oral mucosa, menorrhagia) and post-op bleeding.

There are three main phenotypes of vWD.

vWF problem Typical bleeding picture

Type 1 (common)

Reduced levels of vWF Typically associated with mild bleeding

Type 2 (uncommon)

Abnormal structure and function of vWF, several variants

Variable bleeding pattern

Type 3 (rare) Near absence of vWF Patients may behave like those with moderate to severe haemophilia

Notify Haemophilia Nurse (pager 4800) of patients presenting to Emergency between 0800 - 1630, Monday to Friday. Notify Haematologist on call of patients presenting after hours with bleeding problems.

Assessment

Assess site and extent of bleeding.

Assess type and severity of vWD, if known. Refer to RCH Emergency Department alert system for individual treatment plan.

Management

Antifibrinolytics (Tranexamic Acid)

Often helpful for mucosal bleeding (most common form of bleeding) - mouth, epistaxis, menorrhagia.

May be given alone or as adjunct therapy to DDAVP/factor concentrate. Dose of tranexamic acid (500mg tabs) 25mg/kg/dose (max:1.5g/dose) tds orally for 5-7 days

Weight (kg) Tranexamic acid

< 20 250 mg tds

20 – 30 500 mg tds

30 – 40 750 mg tds

> 40 1 g tds

DDAVP (desmopressin)

Patients with mild to moderate Type 1 vWF can be treated with DDAVP when there is documented evidence in the medical record of safe and satisfactory response (DDAVP challenge). At RCH DDAVP challenge is performed from around 5 years of age.

Occasionally effective in Type 2 vWD, never effective in Type 3 vWD. Expect two to three fold increase in Factor VIII/vWF level. Generally not recommended in young children (< 3 years) due to documented reports of

hyponatraemia and seizures. Relatively contraindicated in children with previous seizure disorders.

DDAVP Dose: 0.3 microgram/kg (max 20 microgram) in 50mls 0.9%NaCl given by intravenous infusion over at least 30 minutes. (Available as 4microgram/ml injection).

Von Willebrand Factor/FVIII Plasma Concentrate (Biostate )

A human plasma-derived product, available from blood bank May be required in Type 1 vWD if severe bleeding or unresponsive to DDAVP Used to treat bleeding in patients with Type 2 and Type 3 vWD. Each reconstituted vial of BiostateTM contains 50 IU/ml FVIII and 100 IU/ml von Willebrand

factor Note that recombinant FVIII products do not contain von Willebrand factor

Recommended dosage (note dosage according to Factor VIII units):

Type of bleeding Dose of Biostate

Oral mucosa/epistaxis/menorrhagia 25 FVIII units/kg

GI/GU bleed 40 FVIII units/kg

Joint/Muscle 40 FVIII units/kg

CNS bleed 60 FVIII units/kg

Trauma or surgery 60 FVIII units/kg

Weight Management

1. Introduction 2. Definition of terms

3. Background 4. Assessment 5. Addressing the Issue of Obesity 6. Management 7. Follow up Review/Referral 8. Resources

1. Introduction

Childhood obesity and overweight now rivals asthma as Australia's most prevalent chronic childhood condition. Over one quarter of Victoria’s children are overweight, with up to 10% fulfilling criteria for obesity. The prevalence is even higher in children presenting to tertiary paediatric hospitals. However the prevention and management of childhood obesity is not adequately addressed despite a rapid rise in its prevalence.

This guideline is to be used by medical, nursing and allied health staff at the RCH to assist them in assessing and addressing issues of weight and obesity in patients. It provides a simple but evidence based clinical approach for the identification of childhood overweight and obesity and an opportunistic approach to addressing these issues with the family and patient.

The recommendations contained in this guideline do not include a definitive course of management for childhood overweight and obesity but outline the process of referral and include links to appropriate resources.

2. Definition of terms

Body Mass Index: Body Mass Index (BMI) is currently seen by health professionals as the most appropriate measure of adiposity in children.

Calculating Body Mass Index: BMI is calculated by dividing the weight (kg) by the height squared (m2). However calculated BMI values need to be compared with age and sex reference standards due to BMI changes that occur in normal growth.

Overweight: Overweight is defined as a BMI greater than the 85th percentile.

Obesity: Obesity is defined as a BMI greater than the 95th percentile.

3. Background

56% of Australian adults are overweight; 18% are obese 18% Australian children are overweight; 5% are obese From 1985-95 the prevalence of overweight in children doubled and obesity tripled

Consequences of childhood overweight

Much greater risk of adult obesity (a 5 yr old who is obese has 8 times increased risk of adult obesity)

Psychosocial morbidity (bullying, teasing, lower self esteem, poorer socioeconomic prospects) Range of physical morbidities: type 2 diabetes, hypertension, dyslipidemia, non-alcoholic

steatohepatitis, orthopaedic disease, obstructive sleep apnoea infertility

Aetiology of childhood overweight

The large increase in the prevalence of obesity in the last three decades points to widespread environmental and lifestyle changes. And while studies suggest many children will have a genetic predisposition to the development of obesity, it is rare to identify specific chromosomal or genes defects.

Risk factors include:

Genetics � At least 5 single gene defects have been found but these are all extremely rare and all are associated with severe and very early onset obesity and should prompt referral for further assessment.

Environment � Physical inactivity, increase in sedentary behaviour (espescially screen based activities), increased consumption of high fat foods and sugar sweetened drinks, children’s food advertising.

Other risk factors for obesity: early infant feeding, parental obesity, parental encouragement of children to eat, lower socioeconomic status.

Underlying medical conditions: (v rare) secondary obesity may occur due to hypothyroidism, hypercortisolism, growth hormone deficiency and hypothalamic damage

Drugs: steroids, antipsychotic drugs (risperidone) and some antiepileptic medications.

4. Assessment

The Body Mass Index (BMI) is recommended as a practical measure of overweight and obesity in children

Rapid changes in BMI can occur in normal growth BMI varies with age and sex BMI rises in the first year of life, then falls during the preschool year, before rising again into

adolescence (adiposity rebound)

Therefore calculated BMI values need to be compared with age and sex reference standards.

1. Calculate BMI using the BMI calculator. (You will need to know the patients weight and height)

2. Download and print BMI for age percentile charts (Below) 3. Compare and chart BMI on percentile chart

BMI for age percentile charts. (Age: 2 - 20)

GIRLS (download) BMI> 85th percentile suggests overweight

BOYS (download) BMI >95th percentile suggests obesity

BMI for Age percentile charts recommended for use in Australia are developed by the CDC in the US

5. Addressing the Issue of Obesity

The issue of obesity as an important health concern is often not addressed in the clinical setting. Once you have noted that the child is overweight you may address the issue using the following approach

1. Do no harm! � approach with respect but address the issue! 2. Assess child and parent’s perceptions of the issue - do they even see it as a concern? - do

they have differing awareness/concerns? 3. Highlight the issue of weight in the context of health � show the growth chart to the family and

explain what the healthiest weight for their child would be; explain they are still growing in height, so probably do not need to actually lose weight � they need to grow into their weight

4. Ask what they think they could do and possibly suggest some behaviour change ideas ( see below)

5. Organise follow up - the options are local GP, paediatrician or RCH Weight management Clinic.

Note: The RCH weight Management Clinic currently has a 6 month waiting period for a first appointment. It is hoped that a current review of Weight Management Services at RCH will lead to an increase in clinical resources.

Parental Perception

We know that approx 50% of parents of obese children do not perceive that their child is overweight. It is therefore useful to gauge their opinion and experience of this issue as this can shape the ensuing discussion eg ‘What do you think about Sarah’s weight?’

1. They (and she!) may respond that they are aware and concerned about the issue. This is when you can discuss specific behaviour changes (see below) and arrange referral.

2. They may instead state that they think her growth is fine. Then your goal is to raise their awareness of the health issues, not necessarily to solve the problem!

Frame discussion of overweight in terms of health � talk about ‘the healthiest weight for Sarah’. You could respond: ‘Let’s take a look at where Sarah should be on the weight for height chart and I can explain why I am concerned. At 5, Sarah is the weight of an average 8 yr old. This has implications for her future health. We need to slow the rate at which Sarah is putting on weight, and help her grow into her weight’

Some behaviour change ideas you can discuss with families

Physical activity � any increas in activity is an improvement!

1. Aim for ‘lifestyle’ exercise: using the stairs, walking to school, walking the dog 2. Involve the whole family (everyone can benefit regardless of weight status) 3. Use after school time to get outdoors and be active 4. Decrease screen based activities (TV,Computer,Playstation) 5. Have bikes, helmets and balls ready to go � by the door!

Nutrition � and don’t forget drinks!

1. Water is the best drink for kids: cut out cordial, soft drink, fruit juice 2. Better to eat the fruit rather than drink fruit juice 3. Low fat (2%fat) milk (<500mls/day) is preferred for children over 2 years of age 4. Importance of breakfast, regular meals and healthy snacks 5. Basic food label reading � and awareness of the ‘traps’ ie ‘no fat’ might mean large

amounts of sugar and therefore the same number of calories 6. Serving sizes ( does the 5 yr old get served as much as Mum or Dad?) 7. Planning ahead, avoiding regular take-away

Parent Fact Sheet (Children’s Hospital, Westmead)

6. Management

Management of obesity is complex and ongoing.

The aim of this guideline is to provide clinicians with an approach for identifying and addressing issues of overweight and obesity in the clinical setting. Weight management is most successful when addressed in the context of the whole family

Wound dressings - acute traumatic wounds

See also: Lacerations guideline Burns guideline

Background

There are a number of different dressings and techniques available for managing wounds. The majority of wounds in children are acute trauma or surgical wounds.

Objectives of wound dressing

to reduce pain, to apply compression for haemorrhage or venous stasis, to immobilise an injured body part, to protect the wound and surrounding tissue to promote moist wound healing.

Assessment

Elicit a careful history of injury i.e.:

mechanism of injury; associated blood loss; risk of contamination; deeper structure damage; tetanus status; consider Non accidental Iinjury; underlying chronic illness or disability.

Fully examine the injured part in particular checking for

underlying nerve, vessel and tendon damage. This requires assessment of movement while exploring the wound (especially in palmar or hand wounds).

Assess tissue damage or loss

Investigation

Request special investigations where appropriate

xray for radiopaque foreign body or underlying fracture ultrasound is useful for puncture wounds with a radiolucent foreign body such as thorn or

splinter.

Consider referral for plastic or general surgical opinion either in ED or as outpatient

Management

Anaesthesia - see Analgesia and sedation guideline Cleansing - see Laceration guideline Wound closure - see Laceration guideline Dressing: in general keep dressings as simple as possible

Dressing Choices

Dressing types Examples Advantages Disadvantages Indications Contraindications

Semi-permeable – thin, OpSite, Some moisture Exudate may Superficial Highly exudative

adhesive, transparent polyurethrane film

Tegaderm evaporation, Reduces pain. Barrier to external contamination. Allows inspection.

pool, may be traumatic to remove.

wounds.As a secondary dressing.

wounds.

Non adherent Moist (Tulle Gras Dressing) – Gauze impregnated with paraffin or similar. May be impregnated with antiseptics or antibiotics

Jelonet, Unitulle Bactigras, Sofra-Tulle

Reduces adhesion to wound.Moist environment aids healing.

Does not absorb exudate.Requires secondary dressing May induce allergy or delay healing when impregnated

Burns.Wounds healing by secondary intention

Allergy

Non adherent Dry Thin perforated plastic film coating attached to absorbent pad

Melolin, Melolite, Tricose

Low wound adherence.May absorb light exudate.

Not suitable in high exudate Can dry out and stick to wound. May require secondary dressing

Wounds with moderate exudate

Dry wounds (may cause tissue dehydration)

Fixation SheetPorous polyester fabric with adhesive backing

Fixomull, Hypafix, Mefix

Can be used directly on wound site. Conforms to body contours, good pain relief and controls oedema, Remains permeable allowing exudate to escape and be washed and dried off wound.Dressing changes can be left for 5-7 days.

Dressing needs washing with soap and water pat-dried twice daily.Requires application of oil prior to removal – ideally soaked in oil and wrapped in cling film overnight.

Wounds with mild exudate, not needing frequent review

Infected wounds allergy to adhesives

Calcium AlginateNatural polysaccharide from seaweed

Kaltostat Forms gel on wound and hence moist environment. Reduces pain. Can pack cavities.Absorbent in exudative

May require secondary dressing.Not recommended in anaerobic infections.Gel can be confused with slough or

Moderately or highly exudative wounds.Need for haemostasis

Dry wounds or hard eschar

wounds.Promotes haemostasis. Low allergenic.

pus in wound.

Foam DressingsPolyurethane foam dressing with adhesive layer incorporated

PolyMem Moist, highly absorbent and protective

Set size of foam may be limited by wound size

Wounds with mild to moderate exudate.

Dry wounds.Wounds that need frequent review.

Hydrocolloid DressingsPolyurethane film coated with adhesive mass

Duoderm Retains moisture, painless removal.

Avoid on high exudate wounds

Burns (small)Abrasions

Dry woundsInfection

Paper adhesive tapesAdhesive tape may be applied directly to healing laceration

Micropore Non allergenic. Provides wound support

Non absorbent Small wounds Exudative or large wounds.

Decision TreeTypes of wounds and dressing options

Wound Type Dressing options Review times

Dry necrotic wound Moisture retention eg hydrocolloid, semi permeable

3-4 days

Slough – covered wounds Moisture retention and fluid absorption eg hydrocolloid, alginate

3-4 days

Infected wound Avoid semi occlusive dressings. Consider alginate or hydrocolloid if high exudate

1-2 days

Graze, abrasions – clean Film, tulle, fixation sheet or dry

2 days

Graze, abrasions – soiled Dry or tulle 2 days

Puncture wounds or bites Open or dry 2 days

Laceration - suturedLacerations

Open or dry, consider paper tape support after suture removal

3-7days see

Burn-minor Burns Film, medicated tulle, fixation 4-5 days visual

sheet review leave dressing on if healing see

Burn-major or requiring admission eg special areasBurns

Plastic wrap prior to surgical review, medicated tulle

Inpatient review

Chronic wounds eg ulcers, PEG sites etc

Hydrocolloid, alginate, foam 5 days