The ABC of community emergency care 6 ASSESSMENT AND MANAGEMENT OF PAEDIATRIC PRIMARY SURVEY NEGATIVE PATIENTS

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1 The ABC of ommunity emergeny are 6 ASSESSMENT AND MANAGEMENT OF PAEDIATRIC PRIMARY SURVEY NEGATIVE PATIENTS See end of artile for authors affiliations Correspondene to: Mr M Woollard, Department of Aademi Emergeny Mediine, Eduation Centre, The James Cook University Hospital, Marton Road, Middlesbrough TS4 3BW, UK; Malolm.woollard@ ukgateway.net T F Jewkes, M Woollard Emerg Med J 2004; 21: doi: /emj his paper desribes the assessment and findings assoiated with illnesses that ommonly affet hildren. It aims to be a guide to ommon presentations and treatment rather than a omprehensive review of all paediatri onditions. A previous artile has desribed the identifiation and initial management of potentially life threatening problems. Box 1 desribes the objetives for this artile. Box 1 Artile objetives Objetives 1. To desribe the approah to the seondary survey in hildren and its main features 2. To disuss differential diagnosis for hildren with ommon presenting symptoms 3. To desribe the differential diagnosis, management, and disposition of hildren with a range of ommon onditions 4. To review indiators of the need for hospital referral 5. To desribe the are of ommon problems affeting tehnologially assisted hildren 6. To onsider the importane of ommuniation in the are of the sik hild SECONDARY SURVEY A seondary survey will be required on all hildren who have not required transfer to hospital after the primary survey (see artile 5 in this series). Its aim is to fully assess the hild so that deisions about their future management and disposal an be safely made. The SOAPC system (box 2) an be used to undertake this survey but is modified to take aount of the partiular needs of hildren (see artile 5). Box 2 SOAPC assessment strategy Subjetive assessment Objetive examination Analysis and diagnosis Plan (treatment and disposal) Communiation Subjetive assessment Most parents and arers will be very sensitive to hanges in their hildren s health. Consequently if they express onern about their hild s wellbeing they are often right. Ask parents or arers what they think the matter is and, if appropriate, what treatment they might be expeting. They may relate treatments that have helped the hild during similar illnesses, and this will help to identify the parent s expetations about what they believe is required. If neessary, ask parents what onstitutes normal behaviour and appearane for their hild, and to always involve the patient in the disussion. Even toddlers and younger shool age hildren should be spoken to diretly, using language appropriate to their ability to understand. It may be helpful to assess teenagers without parents or guardians present to enourage them to disuss their illness and any onerns they may have openly. As well as a detailed history of the presenting omplaint, details of past illnesses or operations, mediations, and allergies should be sought and reorded, as should the family history. Birth history may also be important, partiularly in infants and younger hildren. On oasion a brief developmental history may also shed light on the problem. 595 Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.

2 596 The parents of hildren with hroni illnesses (suh as renal disease) or ongenital problems are likely to have onsiderable expertise about assessment and management of the ondition as indeed may the hildren themselves. Pratitioners should not be dismissive of the information and suggestions made by expert parents and hildren. Objetive examination Before approahing a hild diretly, observe their general behaviour. Are they passive or ative? Are they playing normally? Do they pay attention to their surroundings? (fig 1). As you approah the hild, onsider their affet. Is this normal for their age group? Have they reated to your presene (perhaps by hiding behind the furniture)? Consider the hild s general ondition do they appear well ared for, or are they grubby and thin? The ontent of the physial examination should be similar to that for an adult, although the order in whih eah system is assessed may be modified depending on the age and behaviour of the hild (see artile 5 in this series on primary survey positive hildren). There are some aspets, however, that are partiularly important to paediatri examination: Temperature Taking the hild s temperature is of limited value in primary are. There are various onfounding problems (suh as whether or not the hild has reeived an antipyreti and what part of the body is used to assess temperature) and the presene or absene of a fever does not onfirm or rule out serious disease. Indeed authorities still debate what the upper limit of normal is. It is, however, reognised that very young babies (for example, less than 6 months old) who have a signifiant fever (greater than 38.5 C) or who are hypothermi are likely to have serious disease. Young hildren may sometimes tolerate very high temperatures (in exess of 40 C) with little apparent disomfort or serious pathology. Signifiant fever an usually be deteted, if no thermometer is available, by touhing the skin of the hild s trunk. Skin The presene of a rash may be signifiant. Note its morphology, pattern, and distribution and assess its signifiane in the light of the assoiated symptoms and signs (fig 2). Figure 1 A happy, alert baby (piture ourtesy of Fiona Mair). Figure 2 Group). Chiken pox (piture ourtesy of the Advaned Life Support ENT The ears should be examined using an aurosope, and the throat for evidene of tonsillitis or other pathology. Retiuloendothelial system Lymphadenopathy may indiate glandular fever, other viral infetions, or less ommon pathology suh as leukaemia. Cervial lymphadenopathy is extremely ommon in upper respiratory trat infetions and its presene may lead the hild to tell you that his or her nek hurts when it is flexed. This should not be onfused with the nek stiffness seen in meningeal irritation. When palpating the abdomen hek for organomegaly. Splenomegaly is fairly ommon in viral illnesses but its presene must be noted and the assessment repeated when the hild reovers to ensure that it resolves. The liver may be palpated without diffiulty in the young baby and is easily pushed down in onditions where the lungs are hyperinflated suh as bronhiolitis. This must be distinguished from atual enlargement suggesting ardia failure, metaboli disorder, or malignany. Blood sugar measurement While blood sugar measurement is essential in all hildren who have a disturbed onsious level, it need not be done routinely in the hild who does not appear to be seriously ill, unless there is a partiular reason suh as a suspiion of diabetes. Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.

3 Urine ultures (refer to general pratitioner) These need to be obtained in any hild who is unwell and in whom the ause is not lear, partiularly in the presene of febrile onvulsions. It is important to obtain urine for ulture before starting antibiotis for suspeted urinary infetion. The parent an be instruted to ollet the urine before starting antibiotis and store it in the refrigerator until the next day, when the hild s GP an send it for ulture. Pitfall There are almost no indiations for a retal or vaginal examination in hildren in the primary are setting Tip Children who grab your stethosope and play with it, and who an be made to laugh by wobbling their tummy are not usually seriously ill! Analysis (differential diagnosis) and treatment and disposal (plan) Common presentations The irritable hild A ommon presentation that an be diffiult to sort out is the baby who is reported to ry exessively. If the baby does indeed appear to be irritable and dislike handling they must be assumed to have serious illness and be admitted urgently to hospital. More ommon is the baby who will not settle or settles only briefly: these hildren an ause onsiderable onern to new parents and healthare professionals alike. The ause may be attributable to a multitude of reasons from signifiant pathology to parents who are inseure and not oping. Even when the pratitioner an onfidently determine there is no signifiant linial problem (diffiult at the best of times) admission to hospital or referral for further support should be onsidered if parents remain anxious. If there is any doubt at all that the hild is genuinely irritable, they should be referred, as the pathology assoiated with irritability is often serious (for example, meningitis). Tip Children who have beome suddenly and unusually irritable should be onsidered to be autely ill until proved otherwise Abdominal pain Abdominal pain in hildren an also ause diagnosti onundrums. If the hild is seriously ill (primary survey positive) they should be managed with immediate transfer to hospital and appropriate resusitative measures. If the hild is not seriously ill, diagnostially they an be divided into aute and hroni presentations. Intermittent hroni abdominal pain in hildren is very ommon but more likely to present as a routine rather than emergeny referral. Causes are diverse and beyond the sope of this disussion some of the ommoner auses are urinary infetion, onstipation, abdominal migraine, and idiopathi (the aptly named reurrent abdominal pain of hildhood ). Aute abdominal pain is ommon and a systemati approah required. Possible surgial pathology must be exluded and if this is not possible, the hild referred for more detailed assessment. Aute appendiitis may be very diffiult to diagnose in small hildren and must be atively onsidered. Urinary trat infetion often presents non-speifially with abdominal pain with or without urinary or systemi symptoms and must also be onsidered. One of the ommonest non-surgial auses is mesenteri adenitis (aute lymphadenopathy in the abdominal lymph nodes) and a onurrent upper respiratory infetion is harateristi. Infetive gastroenteritis, Henoh Shonlein purpura (HSP), and many other disorders all have their own range of assoiated features and symptoms. If in doubt, refer for further investigation. Pitfall Infants and toddlers normally have a protuberant abdomen this should not be onfused with pathologial distension Tip Unilateral pain is a signifiant finding, and the further the pain is from the umbilius the more likely it is to be organi, but remember that small hildren loalise abdominal pain poorly and will tend to point to the umbilius as the loation. The febrile hild Reduing the temperature of febrile hildren does not have any signifiant benefit in reduing the length or severity of the assoiated illness. However, simple antipyretis suh as paraetamol (known as aetaminophen in the USA) or ibuprofen (whih an be used onurrently) an redue the misery for both hild and arer alike. ENT problems ENT problems are ommon in hildren. Infants are obligate nasal breathers up to about 6 months of age. Consequently a bloked nose may result in a signifiant inrease in the work of breathing and may produe diffiulty feeding. Otitis media, presenting with a red and sometimes bulging or perforated eardrum, is a ommon finding in a hild with earahe. Antibiotis have not been shown to hange the outome of the disease in the majority of patients but are still often given. Otitis externa is less ommon, usually also presents as earahe, with or without a disharge. Foreign bodies may be pushed into the ear by small hildren or, more ommonly, into the nose, and should be sought for in the presene of a snuffly hild without symptoms of illness. The throat should be arefully examined in all sik hildren unless epiglottitis or roup is suspeted. Streptooal infetions and glandular fever an ause petehial rashes on the palate, ulers may indiate a oxsakie virus infetion, and Koplik s spots (although very unommon nowadays) are indiative of measles. Swollen red tonsils, with or without exudates, and aompanied by flulike symptoms suggest tonsillitis, and unilateral enlargement may suggest a peri-tonsillar absess. 597 Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.

4 598 Figure 3 Epiglottitis with andida infetion (piture ourtesy of the Advaned Life Support Group). Respiratory problems Respiratory problems aount for about 40% of hildren admitted to hospital and many of these hildren have asthma. Croup is usually viral and presents with a seal like bark with or without systemi illness or assoiated stridor. Sudden onset, short history, drooling beause of pain, and a very toxi hild support the diagnosis of the now rare epiglottitis, whih should be onsidered to be immediately life threatening (fig 3). Wheezing in babies may be attributable to a variety of auses, two of the ommoner ones being asthma or bronhiolitis, the seond resulting in the hospitalisation of 2% 3% of infants eah year. Bronhiolitis is seasonal, ourring in the winter months and lassially fine inspiratory repitations may be heard on ausultaton. In older hildren asthma is a more likely ause, but anaphylaxis should be onsidered as an unlikely possibility in a hild with a first presentation of wheezing (fig 4). Signifiant respiratory trat infetions, inluding pneumonia, also our in hildren and an oasionally result in respiratory failure, septiaemia, hypoglyaemia, or dehydration beause of the inability to feed. Illnesses rarely requiring hospital admission Table 1 desribes ommon illnesses and presentations in hildren that rarely require hospital admission. Upper respiratory trat infetions are partiularly ommon in hildren, but foreign bodies in the airway should always be onsidered as a possible explanation of mild stridor or wheeze in otherwise well hildren. Children are also suseptible to a wide range of viral infetions, many of whih present with rashes of various desriptions. Symptomati treatment for pain or fever onsists of paraetamol or ibuprofen. Both drugs an be used together for their synergisti effet staggering the doses if required. Enourage maintenane of an intake of (preferably) lear fluids. Emerg Med J: first published as /emj on 25 August Downloaded from Figure 4 Urtiarial rash, often seen in anaphylati reations (piture ourtesy of the Advaned Life Support Group/University of Erlangen). Figure 5 Group). Rubella (piture ourtesy of the Advaned Life Support on 21 Deember 2018 by guest. Proteted by opyright.

5 Table 1 Common onditions Diagnosis, treatment, and disposition of ommon hildhood illnesses not requiring hospital admission Subjetive findings Objetive findings (only some may be present and only most ommon are listed) Plan Disposition General Fever Hot and unwell Depends on ause (must be Miserable sought and found) Symptomati treatment May be off food/fluids Cause must be sought (inluding urine ulture if no other ause found) Do not give antibiotis if ause unknown Vomiting Frequeny? blood Rule out: Exlude abdominal or other serious pathology?tolerating lear fluids?bile stained Diarrhoea Need desription?blood?slime?watery?amount? smell Respiratory Upper respiratory trat infetion May be vomiting or anorexi # dehydration # other sign of infetion # Surgial pathology Exlude serious ause Care at home, refer for further investigations if ause annot be identified and hild signifiantly unwell or serious ause annot be exluded If tolerating lear fluids, enourage lear fluids till improving then solid diet Do not give antiemetis Rule out: Enourage lear/ # abdominal abnormalities # signs of dehydration eletrolyte replaement fluids to re-hydrate only # other signs of infetion Exlude oult infetion and dehydration Exlude other abdominal pathology Continue breastfeeding throughout. Reommene solids and formula feeds after re-hydrating Mild fever Avoid foods high in fat or simple sugars Do not give antidiarrhoeal agents Care at home unless very unwell/dehydrated or signifiant pathology annot be exluded Care at home unless very unwell/dehydrated or history of bloody diarrhoea, or signifiant pathology annot be exluded Cough Inflamed throat Symptomati treatment Care at home Cold Otitis media No antibiotis Sore throat Coryza, Review if fluid intake poor Snuffly Chest lear Hot and miserable Fever May be off food Croup (mild) Barking ough Noisy breathing Barking ough May have mild stridor Nebulised budesonide or oral dexamethasone May be worse at night Child not distressed Mild fever possible Asthma (mild) Wheeze Bilateral wheeze Adjustment of dose of Cough Good air entry bronhodilator May be URTI May be tahypnoei Chek tehnique of Child not distressed administration using spaer Oral (soluble) prednisolone Bronhiolitis (mild) URT symptoms followed by lower respiratory symptoms ENT/eyes Conjuntivitis Sore gritty eyes Normal visual auity Care at home unless systemially unwell or deteriorating Care at home unless no response to treatment, deteriorating, or history of previous ITU admission Not distressed Symptomati treatment Care at home; onsider Mild tahypnoea need for follow up visit and enourage reall if ondition Mild fever possible deteriorates (espeially Bilateral inspiratory fine relutane to feed or rakles and wheeze breathing diffiulty). Very low threshold for admission in babies under 2 months old Mildly inflamed onjuntiva, often bilaterally Regular leaning with ooled boiled water Care at home Sometimes purulent disharge Antibioti eye drops Foreign body History of witnessed Foreign body visible May be possible to Care at home if objet insertion of objet in Stridor remove if not refer to removed, otherwise refer to nose, ear Wheeze appropriate speialist A&E Missing objet Unequal air entry Do not attempt to remove blindly if lodged in pharynx Sudden respiratory distress 599 Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.

6 600 Table 1 Continued Common onditions Subjetive findings Tonsillitis Sore throat Systemially unwell Sore nek Diffiulty swallowing Objetive findings (only some may be present and only most ommon are listed) Plan Disposition Swollen inflamed tonsils Exudate Lymphadenopathy Fever Mild symptomati treatment, otherwise peniillin (unless allergi when use suitable alternative) for 10 days and symptomati treatment Care at home with advie to reall if swallowing beomes impossible or airway beomes noisy Teething Miserable Teeth erupting Symptomati treatment Care at home Otitis media Miserable Inflamed ear drum +/2 Symptomati treatment Care at home perforation Consider antibiotis if If eardrum perforated, refer Fever possible very severe or if eardrum is perforated to GP for review and keep ear dry Skin and viral rashes Chiken pox Mild URTI symptoms Blistering rash in rops, (unompliated Rash most severe on trunk see fig 2) Mild fever Sabies Ithy rash Ithy papules, may be more generalised than in adults, with some traks Impetigo Crusting rash Yellow/golden rusting spreading rash May oasionally be systemially unwell May be painful espeially if seondary infetion Symptomati treatment Care at home Non-urgent referral to GP Care at home and nonurgent referral to GP Systemi antibiotis unless very tiny lesion when topial antibiotis may be tried Care at home Advise on reduing spread to other family members Mumps (unompliated) Swollen nek Parotid swelling Symptomati treatment Care at home Diffiulty opening mouth and swallowing Loss of palpable angle of mandible Mild fever/malaise Rubella (see fig 5) Fine pink rash Fine maular rash Symptomati treatment Care at home May be very slightly unwell Roseola infantum High fever whih settles when rash omes out Measles (unompliated see fig 6) Upper respiratory symptoms Neurology Inrease in seizures In hild known to have seizures Posterior ervial lymphadenopathy Minimal systemi upset Chek no ontat with pregnant adult is likely Disrete rash that may oalese Symptomati treatment Care at home May be oedema of eyelids Fever Unwell hild Symptomati treatment Care at home Rash Kopliks spots early in illness Notifiable disease Typial rash Upper respiratory trat signs No sign of ompliations (for example, pneumonia) Infetion or any obvious ause Look for infetion Refer to GP if not urrently Reent hange in mediation dose; not taking mediation or malabsorbing (for example, GI upset) seizing and otherwise well; refer to A&E if urrently seizing or seizures very frequent (see artile 5 on primary survey positive hildren) Head injury (mild) No symptoms May be bruising Rule out signifiant mehanism of injury Headahe Ask for type, when it ours in day, assoiated features If no loss of onsiousness, persistent vomiting, unusual drowsiness, or visual disturbane sine injury, advise that treatment should be sought if these symptoms present Exlude serious infetion Look for signs of raised intra-ranial pressure and meningitis Care at home in the absene of history of loss of onsiousness and signifiant symptoms; advise reall if symptoms present. Provide written head injury instrutions If hild well with no signs of meningitis, provide symptomati treatment and refer to GP Past history investigations Arrange urgent review if unwell or ondition worsens Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.

7 Table 1 Common onditions Subjetive findings Febrile onvulsions Fever, hild known to have febrile onvulsions Abdomen Abdominal pain (oliky) Dysuria Complaining of pain when passing urine Pitfall Continued The hoie of antibioti and some other treatments may vary aording to loal protools or where ompliations our. To hospitalise or not In many situations it an be diffiult to deide whether to send hildren to hospital beause they fall neither into the ategory of primary survey positive patients nor that of the relatively well hild desribed in table 2. The signs of serious illness in hildren are subtle and it is usually wise to err on the safe side and ask for a seond opinion from hospital speialists. However, some pointers that may be helpful in enouraging hospital referral and have been evidene based are given below. 1 Objetive findings (only some may be present and only most ommon are listed) Plan Disposition Fever Infetion Usual age range approx. 6 months to 6 years May be irritable Rule out surgial problem abnormalities Look for assoiated features Ibuprofen is ontraindiated in hildren with asthma Figure 6 Measles (piture ourtesy of the Advaned Life Support Group/University of Erlangen). Loate soure of infetion and treat, referring to hospital if serious ause found or if no ause found Chek blood sugar Exlude appendiitis, obstrution. or other pathology (see above) Symptomati treatment Balanitis possible Mild balanitis an be treated with salt baths Rule out renal tenderness If balanitis is severe will require antibiotis Chek otherwise well or minimum systemi upset If no balanitis hek urine ulture and treat for urinary trat infetion till results of ulture available General Babies less than 2 months old Comorbidity with a hroni disorder for example, ongenital heart disease Lak of soial support parents unable to ope, previous hild abuse Upper airway obstrution Signs of severe respiratory distress Signs of serious illness Strong suspiion of aspiration Stertorous (snoring) breathing Wheezing and oughing Suspiion of foreign body Child under 2 months old Signifiant respiratory distress History of apnoei attak Febrile seizures First febrile onvulsion Infants less than 18 months old with fever or history of treatment with antibiotis Complex seizures Drowsiness before seizure Contat with GP in previous 24 hours Tense fontanelles or possible nek stiffness Vomiting before seizure No fous of infetion Parental anxiety Afebrile seizures Depressed onsious level more than one hour after fit New neurologial signs Age less than 1 year Signs of raised intraranial pressure Complex seizure Signs of meningism Unwell Signs of aspiration Parental anxiety Care at home for simple febrile onvulsions, provided # This is not the first fit # It is a simple onvulsion # The ause of the fever has been identified and is benign # No more than one fit in a 24 hour period # The parents are onfident about aring for the hild If hild is ompletely well, refer to GP. If hild is unwell or parents are onerned, refer urgently to GP or hospital Care at home; refer for further investigations if no ause found 601 Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.

8 602 Table 2 Management of ommon problems in tehnologially assisted hildren Devie Problem(s) Solution(s) Traheostomy tube Obstrution 1 Confirm tube is orretly positioned 2 Remove the speeh ap from fenestrated tubes 3 Sution the tube to remove seretions (use the tube s obturator if sution is not available) 4 Remove the traheostomy tube and replae 5 Ventilate to onfirm orret position and pateny Home ventilator (fig 8) Failure 1 Confirm the problem is not attributable to airway obstrution 2. Assist breathing with a self inflating bag with supplementary oxygen and transport to hospital Central venous atheter 1 Catheter dislodged 1 Dress the wound 2 Apply diret pressure to ontrol bleeding 3 Contat hospital and inform the hild s medial team 2 Broken/perforated atheter 1 Clamp atheter tube proximal to break to prevent air embolus 2 Transfer to hospital 3 Infetion at insertion site/septiaemia 1 Disontinue use 2 If the hild is very ill, transfer treating A, B, C as for primary survey positive patients. Do not remove the atheter! 3.Mild loal infetion will also need hospital review 4 Obstrution 1 Contat hospital and arrange review and disuss need for rehydration/prevention of hypoglyaemia (will depend on the purpose of the tube) Ventriuloperitoneal (VP) shunts Nasogastri or perutaneous feeding tubes (PEGs) Diarrhoea and vomiting Doubt in diagnosis of gastroenteritis Age less than 6 months More than four vomits per day More than eight liquid stools per day 5 Air embolism (after inorret flushing tehnique) 1 Obstrution (ausing raised intraranial pressure) Figure 7 Child with meningooal septiaemia: note petehial rash (piture ourtesy of Fiona Mair). 1 Clamp the tube 2. Transfer urgently to hospital in a head down, left lateral position 3 Give high onentration oxygen 4 Provide CPR if neessary 1 If hild seriously ill treat ABCs and transfer immediately to hospital. 2 Use ontrolled hyperventilation (at a rate of five inflations per minute above the hild s normal respiratory rate) if Cushing s triad present. Otherwise transfer urgently. 2 Infetion/septiaemia 1 Transfer urgently to hospital. Manage as meningitis. 2 Consider need for antibiotis and supportive therapy 1 Dislodged 1 Disontinue use. 2 Remove nasogastri tube if not already out 3 Either replae or arrange transfer to healthare personnel who usually replae tube. (Many parents and some hildren will replae nasogastri tubes themselves). 4 If a PEG is dislodged, arrange transfer to hospital for review by the hild s medial team 2 Infeted site 1 Clean and dress the site. Arrange hospital review. Findings for exlusion if hospital attendane is not onsidered appropriate Viral infetions that ommonly result in hildhood illnesses may oasionally be assoiated with serious ompliations. Mumps, measles, hiken pox, and rubella an all result in Figure 8 Child on home non-invasive ventilation (piture ourtesy of the Advaned Life Support Group). Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.

9 Figure 9 Disposition flow hart. 603 Emerg Med J: first published as /emj on 25 August Downloaded from inflammation and damage of a number of organs. Compliations an inlude meningitis, enephalitis, hepatitis, and panreatitis. Children presenting with these onditions will require urgent referral for supportive treatment. Always onsider meningitis in hildren with flu-like illness who have deteriorated rapidly over four to six hours (fig 7). Children with evidene of dehydration or redued urine output, or both, regardless of ause, may require intravenous fluids inluding dextrose. Abdominal pain will require referral if signifiant pathology annot be ruled out. DISPOSITION FLOW CHART Figure 9 diagrams the deision making proess for determining the urgeny of are required and the appropriate disposition for hildren with a range of presenting problems. on 21 Deember 2018 by guest. Proteted by opyright.

10 604 Table 3 Drugs ommonly used in hildhood illnesses Drug name Indiations Contraindiations Dose Adrenaline (epinephrine) Adrenaline (epinephrine) Benzylpeniillin Anaphylaxis assoiated with wheeze or respiratory distress (inluding yanosis) unrelieved by salbutamol OR stridor OR linial signs of shok (systoli BP,90 mm Hg) Croup assoiated with severe respiratory distress Meningooal septiaemia (also see efotaxime) None None Confirmed peniillin allergy 6 11 years: 250 mg (0.25 ml of 1:1000) IM. 6 months 5 years: 120 mg (0.12 ml of 1:1000) IM.,6 months: 50 mg (0.05 ml of 1:1000) IM. All ages: repeat after five minutes if neessary. 5 ml 1:1000 via nebuliser one only while definitive are arranged For IV/IO use, dilute 600 mg in 10 ml. For IM, dilute 600 mg in 2 ml. Less than 1 year 300 mg (5 ml IV/IO or 1 ml IM) 1 9 years 600 mg (10 ml IV/IO or 2 ml IM).9 years and adult 1.2 g (20 ml IV/IO or 4 ml IM) Budesonide Croup Less than 3 months old 2 mg via nebuliser, one only Cefotaxime Meningooal septiaemia Allergy 80 mg/kg Dexamethasone syrup Croup None 0.15 mg/kg IO Dextrose 10% Hypoglyaemia None 5 ml/kg IV/IO, titrated to blood sugar Diazepam Continuous or reurrent fits None Retal: 0 to 1 years 2.5 mg; 1 to 3 years 5 mg; 4 to 12 years 10 mg. IV: 250 to 400 mg/kg All ages: repeat if required after 5 minutes. Hydroortisone Anaphylaxis; asthma None 4 mg/kg IV Ibuprofen Fever and mild to moderate pain Known sensitivity 10 mg/kg up to thrie daily Asthma Ipratropium bromide Asthma/bronhiolitis None Up to 7 years, 125 mg.7 years 250 mg via nebuliser Morphine Moderate to severe pain Known sensitivity to opioids 0.1 mg/kg, repeated at 5 min intervals to a Respiratory depression, maximum dose of 0.2 mg/kg. Use half dose in hypotension, or redued GCS (,12) hildren less than 1 year old Naloxone Reversal of opioid overdose None 10 mg/kg followed by 100 mg/kg titrated to effet Paraetamol suspension or soluble tablets Prednisolone soluble tablets Fever and mild to moderate pain Under 2 months 15 mg/kg (maximum single dose 1 g) PO 4 6 hourly Exaerbations of asthma None 1 mg/kg (maximum single dose 60 mg) PO, twie daily for 5 days Salbutamol Asthma/bronhiolitis None,1 year 2.5 mg (if ineffetive do not repeat). 1 to 5 years 2.5 mg repeated at 15 min intervals, titrated to effet.5 years 5 mg repeated at 15 min intervals, titrated to effet Fuidi aid eye drops Eye infetion for prophylaxis or treatment Allergy Known allergy to any of the drugs or onstituents is a ontraindiation in all ases. Tip If in doubt, ask for help! (Whih may well inlude seeking a hospital opinion) Pitfall Lak of a non-blanhing rash does not rule out meningooal septiaemia Twie daily TECHNOLOGICALLY ASSISTED CHILDREN Children requiring tehnologial support suh as assisted ventilation and tube feeding are inreasingly being ared for at home. Prehospital pratitioners alled to assist suh hildren may be unfamiliar with this equipment but should be aware of the small number of interventions that an be appropriately made in the out of hospital setting. Remember that both parents, arers, and the hild may be able to offer expert advie themselves, and should also be able to provide ontat details for professional advie. Table 2 desribes a number of problems and relevant interventions. Further information may be found on the journal web site ( Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.

11 Tip Always be sure you are satisfied that any ill hild does not have meningitis, appendiitis, or urinary trat infetion. If you are not ertain, refer for investigation Pitfall If a hild is on ontinuous enteral feeds, remember to monitor for hypoglyaemia if it is neessary to disontinue an infusion COMMUNICATION AND FOLLOW UP Parents do not ask for help unless they are worried. Provide a simple explanation of your findings and of the impliations of these for their hild s health. Offer reassurane and lear parameters for re-ontating the servie if things are not going aording to plan. Where appropriate provide written advie. Always seek help from someone more expert or the hospital if unsure. PHARMACOPOEIA Table 3 desribes the indiations, ontraindiations, and doses of drugs ommonly used to treat illness in hildhood. Further reading Advaned Life Support Group, eds. Advaned paediatri life support. The pratial approah. 3rd ed. Manhester: Advaned Life Support Group, Advaned Life Support Group, eds. Pre-hospital paediatri life support. Manhester: Advaned Life Support Group, Amerian Aademy of Pediatris. Pediatri eduation for prehospital professionals. Sudbury MA: Jones and Bartlett, Behrman RE, Kliegman R. Essentials of paediatris. Philadephia: WB Saunders, Morley CJ, Thornton AJ, Cole TJ, et al. Baby hek. niutools.oron.net.nz/medicals/babychek.html. (aessed 29 Feb 2004). Ninnis N, Glennie L. Lessons from researh for dotors in training. Bristol: Meningitis Researh Foundation, ACKNOWLEDGEMENTS Suggestions made by Peter Drisoll and Jim Wardrope resulted in improvements to an earlier draft of this artile. Our thanks to them and to Fiona Mair, who generously provided her time and expertise to soure the pitures. AUTHOR CONTRIBUTIONS Malolm Woollard wrote the first draft of the paper. Malolm Woollard and Fiona Jewkes edited all subsequent drafts. Further information on tehnologially assisted hildren is available on line ( om/supplemental).... Authors affiliations F Jewkes, Wiltshire Ambulane Servie NHS Trust, UK M Woollard, Pre-hospital Care Researh Unit, Department of Aademi Emergeny Mediine, The James Cook University Hospital/University of Teesside, UK REFERENCE 1 Paediatri Aident and Emergeny Researh Group. Evidene based guidelines for aute management with breathing diffiulty, diarrhoea +/2 vomiting, post-seizure. Cheltenham: Children Nationwide, Emerg Med J: first published as /emj on 25 August Downloaded from on 21 Deember 2018 by guest. Proteted by opyright.