The Sick Child

Report
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Pyrexia
Dyspnoea
Rash
Abdominal pain
Dehydration
Head injury
Key history, exam, differentials, red flags and
management
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Age - generally worried >39.5 except in <3m anything
over 38 significant
Temperature (measured), pattern
Duration >5/7 ?Kawasakis etc
Behaviour ? Drowsy, irritable, poor feeding
Seizure? Description, duration, fhx
Risk factor - CP, prem, immunosuppressed, leukaemia
Improves after antipyretics?
Immunisations UTD?
Foreign travel, ill contacts, dodgy food
May have specific symptoms, cough, wheeze, sob,
limp, joint pain but often non-specific compared to
adults e.g. Irritable, poor feeding
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Airway
Breathing – tachypnoeic, rr, distress
Circulation – cap refill, cool peripheries, tachycardic,
hypotension (late sign), murmur (may be flow)
Disability – AVPU, GCS, grizzly
Exposure and ENT – rashes, mottling,
lymphadenopathy, tonsils, tongue, TMs, abdomen
Fluid and fontanelle – sunken eyes, skin turgor,
mucous membranes, nappies, output
Glucose
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Persistent (5/7>)
Fever + 4 of: bilateral non-purulent conjunctivitis,
cervical lymphadenopathy, membrane changes,
erythema/desquamation ?Kawasaki
Meningism (neck pain, photophobia etc)
Joint pain (swelling, erythema, limp)
No obvious focus
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LRTI, pneumonia, croup, influenza
Tonsillitis, otitis media.
Kawasaki disease
Meningitis
UTI, pyelonephritis
Ostemyelitis, septic arthritis
Wound infections, abscesses
Gastroenteritis
NAI - cerebral bleeds can cause fever, irritablility
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Identify and treat cause appropriately i.e admit to
hospital if needs investigations, iv abx etc
Simple regular antipyretics
Encourage fluids
Not advised to use cold sponging, fans as increases
core temp
(febrile convulsions – the rapid rate of rise not the
actual number is the problem, 6/10 recur, slight
increase risk epilepsy against background population)
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Spotting the sick child https//www.spottingthesickchild.com/fever/keybacground-information/facts-and-figures/42
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NICE quick reference guide May 2007 - Feverish
illness in children (children under 5)
http://www.nice.org.uk/nicemedia/live/11010/3052
4/30524.pdf
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Age (e.g. <1yr bronchiolitis)
Ex-prem (nicu etc)
Parents definition of respiratory distress
Apnoea, cyanosis
Cough
Pyrexia
Noisy breathing (?new)
Feeding (wet nappies)
Fhx atopy (sleep, play disturbance)
Admissions, steroids, intubated?
If has inhalers, compliant? Also frequency when ill.
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ABCDEFG as always!
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Alert and interested? Agitation or lethargy
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Posture (sitting up)
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Speech (if old enough), broken, triggers cough,
hoarseness
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Noisy breathing – coryza, wheeze, stridor, grunting,
strained crying
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RR – tachypnoeic (can be normal if periarrest),
prolonged exp phase
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Respiratory distress – nasal flaring, tracheal tug,
recession - supraclavicular, sternal, intercostal and
subcostal. Accessory muscle use - head bobbing and
abdominal breathing.
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Sats & HR – 98-100%, needs O2 if less than 95%,
tachycardic (can be normal if periarrest).
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Auscultation (not as valuable as small chest so lots of
transmitted sounds) wheeze, creps and air entry.
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PEFR is appropriate age and mild/mod.
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Choking
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Apnoea
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Status asthmaticus
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Bronchiolitis
Asthma
Croup
Pneumonia
Cardiac abnormality
etc
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Depends on cause
if very unwell to hospital e.g needs O2, tiring or poor
feeding
Can try 5-10 puffs salbutamol via spacer, if needs
more than 4hrly needs admission
If facilities try nebuliser
 https://www.spottingthesickchild.com/symp
toms/difficulty-in-breathing/keybackground-information/facts-and-figures/25

Spotting the sick child https://www.spottingthesickchild.com/symptoms/dif
ficulty-in-breathing/key-backgroundinformation/facts-and-figures/25

British Thoracic Society June 2011 Asthma
Management
http://www.britthoracic.org.uk/Portals/0/Guideline
/AsthmGuidelines/sign101%20June%202011.pdf
Parent perspective
Worry!
Likely concerns?
“Her bottom’s ever so red!”
“His cousin’s had chickenpox and now he’s poorly with
these little spots”
“Her eczema’s got much worse, all crusty and weepy”
“He just had some peanut butter then five minutes
later he came out in this rash”
“I’ve done the tumbler test!”
GP perspective
Common presentation
Often benign – viral/fungal/allergic/eczema
Approach
Is the child sick?
Could there be serious underlying disease?
Who will manage them, where, when?
Likely concerns
Meningococcal septicaemia
Anaphylaxis
Toxic shock syndrome
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General features – fever, rigors, conscious level,
irritability, vomiting, breathing difficulty
Feeding, nappies
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Evolution and distribution of rash; itchy?
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Associated symptoms: headache, photophobia,
abdominal pain, joint pain, cough, conjunctivitis
Unwell contacts? Exposure to known allergen?
Recent illness or injury?
Relevant past history – atopy? Food allergy?
Immunisations?
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1. ABCDEFG as always!
2. The rash itself
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Distribution
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Configuration
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Morphology
Meningococcal septicaemia
A sick child: lethargic or irritable, feverish, rigors, not
feeding, joint pain, tense fontanelles. May not have
signs of meningism.
Then the rash:
1.
non-specific erythema
2.
petechial
3.
purpuric
Then cardiovascular collapse
[pictures removed]
Meningococcal disease
Neisseria meningitidis
2/100 000
Serogroup B
50% of cases: children <4y
85% of cases
septicaemic:15-20%
mortality
Peak incidence: winter
Presentation of meningococcal disease
(%)
15
meningitis
septicaemia
1-2 cases per GP career
25
60
both
Immediate management
NICE CG102 June 2010
Suspected meningococcal disease:
Parenteral abx + urgent transfer - 999
Give IM/IV benzylpenicillin:
300mg (<1y) / 600mg (1-9y) / 1.2g
Withhold only if hx of anaphylaxis
DO NOT DELAY TRANSFER FOR ABX
[Suspected bacterial meningitis without non-blanching rash:
Urgent transfer - 999
Parenteral abx only if anticipate significant delay in transfer]
Differentials for purpuric rash
A relatively well child has abdominal pain,
joint pain and this rash:
[pictures removed]
What diagnosis are you considering?
Henoch-Schönlein Purpura
Immune mediated necrotising vasculitis
M>F
Peak incidence 3-8y
Which obs and bedside tests would you do?
BP, urinalysis
Admit?
Pain management, renal assessment,
intussusception
Differentials for purpuric rash
A completely well child with a
petechial/purpuric rash
[picture removed]
Investigate?
FBC: ?ITP (?leukaemia)
Usually acute and transient in children
Admit?
Refer to paediatrician
Anaphylaxis
History of exposure followed by life
threatening hypersensitivity response
A – angiooedema
B – bronchospasm
C – circulatory collapse
Widespread rash usually present:
 urticarial
 erythematous
 combination
Anaphylaxis:
emergency management
999
IM adrenaline 1:1000
0-6y:
6-12y:
>12y:
150 mcg
300 mcg
500 mcg
= 0.15mL
= 0.3mL
= 0.5mL
Toxic shock syndrome
Unwell child with high fever, diarrhoea, recent
hx of minor burn
Burn may appear normal
Widespread erythematous rash – sunburn like;
later desquamates
Admit?
IV antibiotics
More rashes…
Miserable child
Prodrome of fever, malaise, arthralgia
Painful, itchy skin and mucosal lesions
Not drinking
Recent mycoplasma infection
[pictures removed]
Possible diagnosis?
Stevens-Johnson Syndrome
Admit?
May need fluids, antibiotics
More rashes…
Irritable child with fever for 5d +…
[pictures removed]
Kawasaki Disease
Febrile systemic vasculitis
30-70% untreated cases: coronary artery
stenosis/aneurysm
Risk of myocarditis and MI
Admit?
May need IV Ig in acute stage
Aspirin
Symptoms/signs suggestive of:
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Meningococcal septicaemia
Henoch-Schonlein Purpura
Idiopathic Thrombocytopaenic Purpura
Leukaemia
Anaphylaxis
Toxic shock syndrome
Stevens-Johnson syndrome
Kawasaki disease
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Viral
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Fungal
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Eczema
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Allergic
 Approach
 Depends
 Seek
on cause
timely advice, referral or transfer +/appropriate immediate management

Spotting the Sick Child
https://www.spottingthesickchild.com/symptoms/rash/
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NICE clinical guideline CG102 – bacterial meningitis
and meningococcal septicaemia (under 16y)
June 2010
http://guidance.nice.org.uk/CG102
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GP notebook http://www.gpnotebook.co.uk/
TIME FOR A QUICK BREW FOLKS!
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Acute or chronic
SOCRATES
Vomiting ?bilious
Constipation, diarrhoea, bloody
Eating and drinking, appetite
Fever
Growth, failure to thrive
Disturbed sleep
Stress
Dysuria, frequency and back pain (not useful in
young)
Ill contacts, dodgy food, foreign travel
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ABCDEFG as always!
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Pallor
Hydration
Mass (faecal, Wilm’s etc)
Tenderness
Guarding
Bowel sounds
Peritonism
Genitalia, hernia, scrotal oedema
Do NOT do a PR
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Signs of:
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Peritonism
Intussuception (‘redcurrent jelly stool’)
Abdominal mass (?Wilm’s tumour)
Torsion of testes
Vomiting bile (?obstruction)
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Mesenteric adenitis
Appendicitis
Intussuception
Gastoenteritis
Tumour e.g Wilm’s
UTI
Torsion
Hernia
Anxiety
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Identify and treat cause appropriately
Simple analgesia
NBM if suspect surgical cause
Explore stress related issues if relevant

Spotting the sick child –
https://www.spottingthesickchild.com/symptoms/ab
dominal-pain/key-background-information/facts-andfigures/87
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Vomiting when, bilious, blood, frequency, duration
Diarrhoea ?blood, frequency, duration
Abdominal pain
Polyuria, polydipsia
Systemically well ?drowsy
Intake, normal feeding, output, wet nappies
Weight loss
Ill contacts
Recent foreign travel, dodgy food
Consanguity
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ABCDEFG as always!
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Hydration - sunken eyes, sunken fontanelle, reduced
skin turgor, reduced output, dry mucous membranes
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Cold peripheries, tachycardia, reduced cap refill,
hypotension
Symptoms/signs of:
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Pyloric stenosis (projectile vomiting)
DKA (urine dip, bm)
Hypernatraemic dehydration (neuro signs)
(Known) Inborn errors of metabolism
(known) chronic disease e.g. CF or have ileostomy
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Gastroenteritis/gastritis e.g. Rotavirus
UTI
URTI
Abdominal obstruction
DKA
Poor feeding technique
Pyloric stenosis
Refusal e.g tonsillitis
Inborn errors of metabolism
 https://www.spottingthesickchild.com/symp
toms/dehydration/key-backgroundinformation/facts-and-figures/81
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Identify and treat cause.
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If refusal e.g. secondary to tonsillitis, simple
analgesia or difflam may be sufficient to encourage.
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Fluid challenge (diaraloyte, use syringe and record),
if fails, admit for ng/iv fluids
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If DKA or metabolic condition, send A+E urgently as
will need senior input
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http://guidance.nice.org.uk/CG84

Spotting the sick child –
https://www.spottingthesickchild.com/symptoms/de
hydration/key-background-information/facts-andfigures/81
Parent perspective
Worry!
Guilty…
Reasons for attending
“he’s got a cut (big bump) on his head”
“she whacked it really hard”
“he was knocked out”
“she’s not been right since it happened”
GP perspective
Common presentation to CED
300 000 CED attendances per year
May or may not come via GP
GP may have bigger role in after care
Likely concerns
Diffuse axonal injury
Intracranial haemorrhage
Skull fractures
Vigilance for possible non-accidental injury
 Witness
account if possible
 Mechanism
of injury:
forces, height, surface, helmet;
beware falls, RTAs
 LOC/amnesia
 Seizure
 Change
in behaviour
 Drowsiness/agitation
 Headache
 Vomiting
 NAI
risk factors
Implausible MOI/vague hx/eye & ear injuries
 AVPU/GCS
 General
behaviour –
quiet vs persistently drowsy; upset vs
irritable
 Focal
neurology – pupil abnormalities,
limb weakness.
 Scalp:
signs of skull fracture
boggy haematoma, skull depression, Battle’s
sign, panda eyes, bulging fontanelle, CSF
otorhinorrhoea, haemotympanum
superficial wounds
 Full
exposure
especially if concerned re NAI
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Witnessed loss of consciousness > 5 mins
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Amnesia (antegrade or retrograde) > 5 mins
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Abnormal drowsiness
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3 or more discrete episodes of vomiting
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Clinical suspicion of NAI
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Post-traumatic seizure but no history of epilepsy
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Age > 1 year: GCS < 14
Age < 1 year: GCS (paediatric) < 15
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Suspect open/depressed skull or tense fontanelle
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Any sign of basal skull fracture
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Focal neurological deficit
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Age < 1 year: bruise, swelling or laceration > 5 cm
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Dangerous mechanism (high-speed RTA, fall from > 3 m,
high-speed injury from projectile or an object)
Any one of these in a child is an indication for
a CT head
(NICE CG56, September 2007)
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Simple analgesia if indicated
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If any red flags: CED; consider 999 + NBM
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If well but concerned re NAI: refer to paediatrics
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Close & dress wounds if competent and if confident
the injury is non-significant
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Safety netting, written advice if sending home
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NICE clinical guideline CG56 - Head Injury
September 2007
http://guidance.nice.org.uk/CG56
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Spotting the sick child https://www.spottingthesickchild.com/symptoms/head injury/

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