Documente Academic
Documente Profesional
Documente Cultură
In association with
Paediatric
Guidelines
2010-12
CONTENTS 1/3
Preface.......................................................................................................................... 6
Acknowledgements....................................................................................................... 8
C: CARDIOVASCULAR DISEASE
Cyanotic congenital heart disease.............................................................................. 62
Heart failure and weak pulses.................................................................................... 64
ECG interpretation...................................................................................................... 66
Tachycardia and bradycardia...................................................................................... 70
Endocarditis prophylaxis............................................................................................. 75
E: ENDOCRINE/METABOLISM
Diabetes and fasting................................................................................................... 90
Diabetic ketoacidosis...................................................................................................93
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CONTENTS 2/3
Diabetes new (non-ketotic)......................................................................................... 99
Hypoglycaemia .........................................................................................................101
Ketone monitoring..................................................................................................... 107
Steroid dependence .................................................................................................108
G: GASTROENTEROLOGY
Abdominal pain......................................................................................................... 110
Constipation.............................................................................................................. 112
Diarrhoea and vomiting............................................................................................. 116
Nutritional first line advice ........................................................................................ 122
Failure to thrive..........................................................................................................125
Jaundice ...................................................................................................................127
H: HAEMATOLOGY
Blood and platelet transfusions.................................................................................130
Febrile neutropenia................................................................................................... 131
Henoch-Schnlein purpura....................................................................................... 134
Idiopathic thrombocytopenic purpura (ITP)...............................................................136
Haemophilia.............................................................................................................. 138
I: INFECTION
Antibiotics.................................................................................................................. 141
Bites.......................................................................................................................... 142
Cervical lymphadenopathy........................................................................................ 143
Fever New for 2010-12 .................................................................................................... 147
Hepatitis.................................................................................................................... 150
HIV and hepatitis B post-exposure prophylaxis (PEP)............................................. 151
New for 2010-12
HIV infection testing .................................................................................................
153
Immunodeficiency......................................................................................................155
Kawasaki disease......................................................................................................157
Malaria...................................................................................................................... 159
Meningitis.................................................................................................................. 161
Notifiable infectious diseases and food poisoning.................................................... 165
Orbital cellulitis.......................................................................................................... 167
Osteomyelitis and septic arthritis.............................................................................. 168
Petechial/purpuric rashes..........................................................................................173
Septicaemia (including meningococcal)....................................................................174
Tuberculosis.............................................................................................................. 177
N: NEUROLOGY
Facial palsy................................................................................................................180
Epilepsy..................................................................................................................... 181
Status epilepticus...................................................................................................... 186
New for 2010-12
Neuromuscular disorders .........................................................................................187
Glasgow coma score.................................................................................................189
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CONTENTS 3/3
P: PROTECTION
Child protection......................................................................................................... 190
Child sexual abuse.................................................................................................... 194
New for 2010-12
Self-harm .................................................................................................................
197
R: RENAL
Glomerulonephritis.................................................................................................... 198
Haemolytic uraemic syndrome..................................................................................200
Hypertension.............................................................................................................202
Nephrotic syndrome.................................................................................................. 206
Renal calculi..............................................................................................................210
Renal failure.............................................................................................................. 213
Renal investigations.................................................................................................. 216
Urinary tract infection................................................................................................ 219
R: RHEUMATOLOGY
Arthritis...................................................................................................................... 223
Limping child............................................................................................................. 224
Index..........................................................................................................................227
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PREFACE 1/2
This book has been compiled as an aide-mmoire for all staff concerned with the
management of general medical paediatric patients, especially those who present as
emergencies.
Guidelines on the management of common medical conditions
No guideline will apply to every patient, even where the diagnosis is clear-cut; there will
always be exceptions. These guidelines are not intended as a substitute for logical
thought and must be tempered by clinical judgement in the individual patient.
Practical procedures
DO NOT attempt to carry out any of these Practical procedures unless you have been
trained to do so and have demonstrated your competence
Evidence base
These have been written with reference to published medical literature and amended
after extensive consultation. Wherever possible, the recommendations made are
evidence based. Where no clear evidence has been identified from published literature
the advice given represents a consensus of the expert authors and their peers and is
based on their practical experience
Supporting information
Where possible the guidelines are based on evidence from published literature. It is
intended that the evidence relating to statements made in the guidelines and its quality
will be made explicit.
Where supporting evidence has been identified it is graded I to V according to standard
criteria of validity and methodological quality as detailed in the table below. A summary
of the evidence supporting each statement is available, with the original sources
referenced (ward-based copies only). The evidence summaries are being developed on
a rolling programme which will be updated as each guideline is reviewed.
Level of evidence
Strength of evidence
II
III
IV
V
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PREFACE 2/2
Feedback
Evaluating the evidence-base of these guidelines involves continuous review of both
new and existing literature. The editors encourage you to challenge the evidence
provided in this document. If you know of evidence that contradicts, or additional
evidence in support of the advice given in these guidelines please contact us.
The accuracy of the detailed advice given has been subject to exhaustive checks.
However, if any errors or omissions become apparent contact us so these can be
amended in the next review, or, if necessary, be brought to the urgent attention of users.
Constructive comments or suggestions would also be welcome.
Contact
Partners in Paediatrics, via www.partnersinpaediatrics.org.uk or Bedside clinical
guidelines partnership via e-mail: bedsideclinicalguidelines@uhns.nhs.uk
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ACKNOWLEDGEMENTS 1/1
Contributors
Mona Abdel-Hady
John Alexander
Maggie Babb
Sue Bell
Robert Brown
Deepak Chandra
Alistair Cranston
Karen Davies
Shireen Edmends
Sarah Goddard
Melissa Hubbard
Deirdre Kelly
Jackie Kilding
Aswath Kumar
Warren Lenney
Paddy McMaster
Andy Magnay
David Milford
Angela Moore
Ros Negrcyz
Tina Newton
Anna Pigott
Pawel Politylo
Ros Quinlivan
Parakkal Raffeeq
Clive Ryder
Martin Samuels
Ravi Singh
Tricia Smith
Andy Spencer
Sarah Thompson
Eve Tsouna
Pharmacist
Helen Haley
Microbiology reviewer
Krishna Banavathi
Paediatric Editors
Loveday Jago
Andrew Cowley
John Alexander
Paddy McMaster
Partners in Paediatrics
Loveday Jago
Andrew Cowley
Andy Spencer
Lesley Hines
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Breathing (B)
Airway (A)
l Inspect mouth: apply suction if
necessary
l Use either head tilt and chin lift or jaw
thrust
l Oro- or nasopharyngeal airway
l Intubation:
l endotracheal tube sizes
l term newborns 33.5 mm
l aged 1 yr 4.5 mm
l aged >1 yr: use formula [(age/4) + 4]
mm for uncuffed tubes; 0.5 smaller for
cuffed
l If airway cannot be achieved by other
means, cricothyrotomy
Aged <12 yr
Endotracheal
tube (ETT)
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Circulation (C)
l Cardiac compression rate:
100120/min depressing lower half of
sternum by at least one third: push
hard, push fast
l Peripheral venous access: one to two
attempts (<30 sec)
l Intraosseous access: 23 cm below
tibial tuberosity (see Intraosseous
infusion guideline)
l Use ECG monitor to decide between:
l a non-shockable rhythm: asystole or
pulseless electrical activity (PEA) i.e.
electromechanical dissociation
OR
l a shockable rhythm: ventricular
fibrillation or pulseless ventricular
tachycardia
Algorithm for managing these rhythms
follows:
l If arrest rhythm changes, restart
algorithm
l If organised electrical activity seen,
check pulse and for signs of circulation
Aged 12 yr adult
Notes
1 mg
(10 mL of 1 in
10,000)
Initial and
usual
subsequent
dose
If given by
intraosseous route
flush with sodium
chloride 0.9%
100 microgram/kg
(0.1 mL/kg of 1 in 1000
or
1 mL/kg of 1 in 10,000)
5 mg
(5 mL of 1 in
1000)
Maximum dose is
5 mL of 1 in 1000
100 microgram/kg
(0.1 mL/kg of 1 in 1000
or
1 mL/kg of 1 in 10,000)
5 mg
(5 mL of 1 in
1000)
Exceptional
circumstances
(e.g. betablocker
overdose)
-
5 rescue breaths
CPR
15 chest compressions: 2 ventilations
VF/
pulseless VT
2 min CPR
DC Shock 4J/kg
Assess
rhythm
Asystole/
PEA
High flow O2
IV/IO access
If able intubate
Adrenaline after 3 DC
shock and then every
alternate DC shock
10 microgram/kg
IV or IO
rd
2 min CPR
Continue CPR
High flow O2
IV/IO access
If able intubate
Return of
spontaneous
circulation
(ROSC)
see Postresuscitation
management
Adrenaline
immediately and
then every 4 min
10 microgram/kg
IV or IO
Consider 4 Hs and 4 Ts
If signs of life, check rhythm
If perfusable rhythm, check pulse
10
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PARENTAL PRESENCE
l Evidence suggests that presence at
their childs side during resuscitation
enables parents to gain a realistic
understanding of efforts made to
save their child. They may
subsequently show less anxiety and
depression
l Designate one staff member to
support parents and explain all
actions
WHEN TO STOP
RESUSCITATION
l Unless exceptions exist, it is
reasonable to stop after 30 min of
CPR if you find:
l Exceptions include:
l hypothermia (<32oC)
POST-RESUSCITATION
MANAGEMENT
Identify and treat underlying
cause
Monitor
l Heart rate and rhythm
l O2 saturation
l CO2 monitoring
l Urine output
Request
l Chest X-ray
l 12-lead ECG
l Transfer to PICU
l Hold a team debriefing session to
reflect on practice
11
Assessment
Airway (A) and Breathing (B)
l Effort of breathing
l respiratory rate
l recession
l use of accessory muscles
l additional sounds: stridor, wheeze,
grunting
l flaring of nostrils
l Efficacy of breathing
l chest movement and symmetry
l breath sounds
l SpO2 in air
Circulation (C)
l
l
l
l
l
l
l
Heart rate
Pulse volume
peripheral
central (carotid/femoral)
Blood pressure
Capillary refill time
Skin colour and temperature
Disability (D)
l Conscious level
l Posture
l Pupils
Exposure (E)
l Fever
l Skin rashes, bruising
RECOGNITION AND
ASSESSMENT OF THE SICK
CHILD
Weight
Anticipated weight in relation to age
Age
Weight
Birth
3.5 kg
5 months
7 kg
1 yr
10 kg
Airway
Primary assessment of airway
l Vocalisations (e.g. crying or talking)
indicate ventilation and some degree
of airway patency
l Assess patency by:
l looking for chest and/or abdominal
movement
l listening for breath sounds
l feeling for expired air
l Assess
l effort of breathing
l efficacy of breathing
l effects of respiratory failure
Effort of breathing
l Respiratory rates at rest at different
ages
Age (yr)
<1
3040
12
2535
35
2530
612
2025
>12
1520
l Respiratory rate:
l tachypnoea: from either lung or
airway disease or metabolic acidosis
l bradypnoea: due to fatigue, raised
intracranial pressure, or pre-terminal
l Recession:
l intercostal, subcostal or sternal
recession shows increased effort of
breathing
l degree of recession indicates severity
of respiratory difficulty
l in child with exhaustion, chest
movement and recession will
decrease
l Inspiratory or expiratory noises:
l stridor, usually inspiratory, indicates
laryngeal or tracheal obstruction
l wheeze, predominantly expiratory,
indicates lower airway obstruction
l volume of noise is not an indicator of
severity
l Grunting:
l a sign of severe respiratory distress
l can also occur in intracranial and
intra-abdominal emergencies
l Accessory muscle use
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Efficacy of breathing
l Breath sounds on auscultation:
l reduced or absent
l bronchial
l symmetrical or asymmetric
l Chest expansion and, more
importantly in infants, abdominal seesawing
l Pulse oximetry
l Heart rate:
l increased by hypoxia, fever or stress
l bradycardia a pre-terminal sign
l Skin colour:
l hypoxia first causes vasoconstriction
and pallor (via catecholamine release)
l cyanosis is a late and pre-terminal sign
l some children with congenital heart
disease may be permanently
cyanosed and O2 may have little effect
l Mental status:
l hypoxic child will be agitated first,
then drowsy and unconscious
l pulse oximetry can be difficult to
achieve in agitated child owing to
movement artefact
13
<1
110160
12
100150
35
95140
612
80120
>12
60100
Pulse volume
l Absent peripheral pulses or reduced
central pulses indicate shock
Capillary refill
l Pressure on centre of sternum or a
digit for 5 sec should be followed by
return of circulation in skin within
2 sec
l can be prolonged by shock or cold
environmental temperatures
l not a specific or sensitive sign of
shock
l should not be used alone as a guide
to response to treatment
BP
l Cuff should cover >80% of length of
upper arm
l expected systolic BP = 80 + (age in
yrs x 2)
l Hypotension is a late and pre-terminal
sign of circulatory failure
Effects of circulatory
inadequacy on other
organs/physiology
l Respiratory system:
l tachypnoea and hyperventilation
occurs with acidosis
l Skin:
l pale or mottled skin colour indicates
poor perfusion
14
l Mental status:
l agitation, then drowsiness leading to
unconsciousness
l Urinary output:
l <1 mL/kg/hr (<2 mL/kg/hr in infants)
indicates inadequate renal perfusion
Disability
Primary assessment of
disability
l Always assess and treat airway,
breathing and circulatory problems
before undertaking neurological
assessment:
l respiratory and circulatory failure will
have central neurological effects
l central neurological conditions (e.g.
meningitis, raised intracranial
pressure, status epilepticus) will have
both respiratory and circulatory
consequences
Neurological function
l Conscious level: AVPU (Figure 1); a
painful central stimulus may be
applied by sternal pressure or by
pulling frontal hair
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Alert
- responds to Voice
- responds to Pain
Unresponsive
l Posture:
l hypotonia
l decorticate or decerebrate postures
may only be elicited by a painful
stimulus
l Pupils look for:
l pupil size, reactivity and symmetry
l dilated, unreactive or unequal pupils
indicate serious brain disorders
Respiratory effects
l Raised intracranial pressure may
induce:
l hyperventilation
l Cheyne-Stokes breathing
l slow, sighing respiration
l apnoea
Circulatory effects
l Raised intracranial pressure may
induce:
l systemic hypertension
l sinus bradycardia
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15
EQUIPMENT
l Intraosseous infusion needles for
manual insertion or EZ-IO drill on
resuscitation trolley
l Alcohol swabs to clean skin
l 5 mL syringe to aspirate and confirm
correct position
l 10 mL sodium chloride 0.9% flush
l 20 mL syringe to administer fluid
boluses
l Infusion fluid
16
PROCEDURE
Preferred sites
Avoid fractured bones and
limbs with fractures proximal to
possible sites
Proximal tibia
l Identify anteromedial surface of tibia
13 cm below tibial tuberosity
l Direct needle away from knee at
approx 60 to long axis of tibia
l Needle entry into marrow cavity
accompanied by loss of resistance,
sustained erect posture of needle
without support and free fluid infusion
l Connect 5 mL syringe and confirm
correct position by aspirating bone
marrow contents or flushing with
sodium chloride 0.9% 5 mL without
encountering resistance
l Secure needle with tape
l Use 20 mL syringe to deliver bolus of
resuscitation fluid
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Distal tibia
COMPLICATIONS
Distal femur
l If tibia fractured, use lower end of
femur on anterolateral surface, 3 cm
above lateral condyle, directing
needle away from epiphysiss
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l Bleeding
l Infection
l revert to central or peripheral venous
access as soon as possible
l Compartment syndrome
l observe and measure limb
circumference regularly
l Palpate distal pulses and assess
perfusion distal to IO access site
17
Urgent
l Nasopharyngeal aspirate for virology
l Per-nasal swab for pertussis
l consciousness
l ECG
l colour
l movement
l muscle tone
l Chest X-ray
MANAGEMENT
Clinical history or examination
l If diagnosis apparent from clinical
history or examination, investigate
diagnosis
Assessment
l SpO2
l Fundoscopy by paediatric
ophthalmologist if:
l recurrent
Investigations
Immediate
l FBC
l Blood glucose
l Plasma lactate
l Blood gases
l Blood culture
18
After 24 hr observation
l If event brief and child completely well:
l reassure parents and offer
resuscitation training
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Further investigation
Exclude following disorders:
Gastro-oesophageal reflux
Seizures
Intracranial abnormalities
Cardiac arrhythmias
Upper airway disorder
Hypocalcaemia
Metabolic assessment
Abuse
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pH study
EEG
CT or MRI brain
ECG and 24 hr ECG
Sleep study
Ca and bone screen
Urinary amino and organic acids
Plasma amino acids and carnitine metabolites
(e.g. MCAD)
Skeletal survey (including CT brain)
Blood and urine toxicology
Continuous physiological or video recordings
19
ANAPHYLAXIS 1/2
DEFINITION
Sudden onset systemic life-threatening
allergic reaction to food, medication,
contrast material, anaesthetic agents,
insect sting or latex, involving either:
l Circulatory failure (shock)
l Difficulty breathing from one or more
of following:
l stridor
l bronchospasm
l rapid swelling of tongue, causing
difficulty in swallowing or speaking
IMMEDIATE TREATMENT
Widespread facial or peripheral
oedema with a rash in absence
of above symptoms do not
justify adrenaline or
hydrocortisone. Give
chlorphenamine orally
l See Management of anaphylaxis
algorithm
l Remove allergen if possible
l Call for help
l IM adrenaline: dose by age (see
algorithm) or 10 microgram/kg:
l 0.1 mL/kg of 1:10,000 in infants (up
to 10 kg = 1 mL)
l 0.01 mL/kg of 1:1,000 (max 0.5 mL
= 0.5 mg)
l give in anterolateral thigh
l ABC approach: provide BLS as needed
l monitor SpO2, non-invasive blood
pressure and ECG (see algorithm)
l Repeat adrenaline after 5 min if no
response
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ANAPHYLAXIS 2/2
Management of Anaphylaxis
Remove
allergen
Intubation
or surgical airway
Complete
obstruction
Adrenaline IM
Partial
obstruction/ Nebulised adrenaline
Repeat nebuliser every
stridor
10 min as required
Hydrocortisone
Assess
A
No problem
Bag-mask ventilation
Adrenaline IM
Hydrocortisone
Apnoea
Assess
B
Wheeze
Assess
C
Shock
Adrenaline IM
Nebulised salbutamol
Repeat salbutamol as
required
Hydrocortisone
Consider salbutamol IV or
aminophylline IV
No problem
No pulse
Adrenaline IM
Crystaloid
Adrenaline IV infusion
No problem
Re-assess No problem
ABC
Drugs in
anaphylaxis
Adrenaline IM:
pre-hospital
practitioners
Antihistamine 48 hr to
prevent recurrence
Dosage by age
<6 months
6 months6 yr
150 micrograms
(0.15 mL of 1:1,000)
612 yr
>12 yr
300 micrograms
(0.3 mL of
1:1,000)
500 micrograms
(0.5 mL of
1:1,000)
Adrenaline IM:
in-hospital
practitioners
10 micrograms/kg
0.1 mL/kg of 1:10,000 (infants and young children) OR
0.01 mL/kg of 1:1,000 (older children)1
Adrenaline IV
Crystalloid
Hydrocortisone
(IM or slow IV)
1
20 mL/kg
25 mg
50 mg
100 mg
200 mg
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21
FLACC
Behavioural
CATEGORIES
No particular expression or
smile
Normal position or relaxed
Face
Legs
2 months to 7 years
SCORING
1
Activity
10
From Wong D.L., Hockenberry-Eaton M., Wilson D., Winkelstein M.L., Schwartz P.: Wong's Essentials of Pediatric
Nursing, ed. 6, St. Louis, 2001, p. 1301. Copyrighted by Mosby, Inc. Reprinted by permission
Analgesic interventions
Analgesic ladder
Increasing Pain
0
1-3
4-7
8-10
=
=
=
=
No pain
Mild pain
Moderate pain
Severe pain
Moderate
Mild
Paracetamol,
NSAID +
weak opioid
e.g. Codeine
Play Specialist
Intervention by play staff
Severe
Paracetamol,
NSAID +
potent opioid
e.g. Morphine
(PCA / NCA)
Paracetamol,
+NSAID
Slight
Paracetamol
22
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ANALGESIA 1/4
l For combination of analgesics to use, see Analgesic ladder in Pain assessment
guideline
TOPICAL
Age group
<1 month
Time to onset
During procedure
111 months
15 yr
Preparation
Glucose syrup on pacifier
(available as a tootsweet)
Ametop
EMLA
>5 yr
Ethyl chloride
Immediately
30 min
1 hr
Comments
For venepuncture or
cannulation
Causes itch, lasts 4 hrs
Remove after 1 hr
(see instructions leaflet)
If cannot wait for EMLA
Paracetamol
(rectal)
l Suppositories
l 60 mg
l 125 mg
l 250 mg
l 500 mg
l1g
Dose
l First dose 20 mg/kg
THEN
l 1520 mg/kg/dose 4-6 hrly:
l aged 311 months:
60120 mg/dose
l aged 15 yr: 120240 mg/dose
l aged 612 yr: 250500 mg/dose
l aged >12 yr: 500 mg1 g/dose
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Maximum dose
Max total dose
in 24 hr
l Aged
<3 months:
60 mg/kg
l Aged
3 months:
90 mg/kg
l Aged
>12 yr: 4 g
l reduce after
48 hr
l Max total
dose in 24 hr:
l aged
<3 months:
60 mg/kg
l aged
3 months:
90 mg/kg
for 48 hr then
60 mg/kg
l aged >12 yr:
4g
l Max 30
mg/kg/day
l Max total
dose 60
mg/kg/day
l Up to 4 g
daily
Comments
l For mild pain
l Increase dose
interval in renal
impairment
l Avoid large doses in
hepatic impairment
l As for oral
paracetamol
l For mild pain when
oral/NG route not
possible
l As for oral
paracetamol
l For mild pain when
oral/NG/PR route not
possible
23
ANALGESIA 2/4
MODERATE PAIN (pain score 47)
Drug and preparation
Ibuprofen
l Liquid 100 mg/5 mL
l Tablets 200 mg and
400 mg
Dose
l Aged 3
months12 yr:
5 mg/kg
68 hrly
l Aged 12 yr:
200600 mg
68 hrly
Diclofenac
l Aged >6
months: 300
l Tablets:
micrograms1
l dispersible 50 mg
mg/kg 8 hrly
(can be used to give
smaller doses)
l enteric coated 25 mg
and 50 mg
l Suppositories
12.5 mg, 25 mg,
50 mg and 100 mg
Codeine
l Liquid 25 mg/5 mL
l Tablets 15 mg, 30
mg and 60 mg
Maximum
dose
l Aged
<12 yr:
max 30
mg/kg/day
l Aged
12 yr:
max
2.4 g/day
l Max
150
mg/day
l Max
l Aged <12 yr:
240
500 micrograms
mg/day
1 mg/kg
46 hrly
l Aged 12 yr:
3060 mg
46 hrly
Comments
l If aged <3 months or <5 kg use
only if recommended by consultant
l Avoid in renal dysfunction
l Contraindications:
l shock
l bleeding disorders
l hypersensitive to aspirin or other
NSAID
l Can be given to asthmatics if no
history of NSAID-induced
wheeze and chest clear on
auscultation
l As ibuprofen
24
Dose
l
l
l
l
Aged 12 yr:
200400 microgram/kg 4 hrly
Aged 212 yr:
200500 microgram/kg 4 hrly
(max 20 mg)
l Aged >12 yr:
l 520 mg 4 hrly
Monitoring
l
l
l
l
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ANALGESIA 3/4
Analgesic method and
technique
Morphine patient/nursecontrolled analgesia
(PCA/NCA)
l PCA suitable for children
aged >5 yr (understand
and will press button);
NCA otherwise
l Nurses must be certified
competent in use of
PCA/NCA
l Use anti-reflux valve
unless dedicated cannula
l Use morphine 1 mg/kg
made up to 50 mL with
sodium chloride 0.9%
l thus 1 mL =
20 microgram/kg
l maximum of 50 mg/50 mL
Morphine infusion
l Use for severe pain when
unable to use PCA/NCA
l Use anti-reflux valve
unless dedicated cannula
l Use anti-syphon valve on
line
l Use morphine 1 mg/kg
made up to 50 mL with
sodium chloride 0.9%
l 1 mL/hr = 20
microgram/kg/hr; 2 mL/hr
= 40 microgram/kg/hr
l max 50 mg/50 mL
IV intermittent morphine
l Infusion preferable
SC intermittent opioid
l IV preferable
l Site 22/24 g SC cannula
at time of surgery or using
EMLA cream
l suitable sites: uppermost
arm, abdominal skin
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Dose
l
l
l
l
l
l
l
l Loading dose of
100200 microgram/kg given
over 520 min
l Continuous infusion of
1040 microgram/kg/hr
l Start at 1 mL/hr
(= 20 microgram/kg/hr)
except after major surgery
when start at 2 mL/hr
(= 40 microgram/kg/hr) and
adjust according to pain and
sedation scores
l
l
l
l
l
Monitoring
Hourly observations
l Pain score
l Sedation score
l Pump displays
l Syringe movement
l Respiratory rate
l SpO2 if needed
l TcCO2 if needed
4 hourly observations
l Vomiting/itching
l Urinary retention
l Inspection of IV site
Hourly observations
l Pain score
l Sedation score
l Respiratory rate (as above)
l SpO2 monitoring
l Syringe movement
l IV site for infection
l Urinary retention
Hourly observations
l Pain score
l Sedation score
l Respiratory rate (as above)
l SpO2 monitoring
l Pain score
l Sedation score
l Respiratory rate (as above)
25
ANALGESIA 4/4
SEVERE PAIN IN CHILDREN AGED <1 YR (pain score 810)
In head injuries/respiratory difficulties/upper airway obstruction,
only use opioids with consultant advice. Monitor children requiring
O2 and parenteral opioids with SpO2 +/- TcCO2 in an HDU setting
Analgesic method and
technique
Oral morphine
l Use if no IV access or for
weaning from IV opiate
Morphine infusion
l Use anti-reflux valve
unless dedicated cannula
l Use anti-syphon valve on
line
l Use morphine 1 mg/kg
made up to 50 mL with
sodium chloride 0.9%
l thus 1 mL/hr =
20 microgram/kg/hr
IV intermittent morphine
l Infusion preferable
SC intermittent opiate
l IV preferable
l Site 24 g SC cannula at
time of surgery or using
EMLA cream
l suitable sites:
uppermost arm,
abdominal skin
26
Dose
l Aged 112 months:
l 100 microgram/kg 4 hrly
l max 5 doses in 24 hr
l Aged 36 months:
l loading dose 2550
microgram/kg over 3060 min
l continuous infusion of 1030
microgram/kg/hr (0.51.5
mL/hr)
l Aged 712 months:
l loading dose 100
microgram/kg over 3060 min
l continuous infusion of
1040 microgram/kg/hr
(0.52 mL/hr)
l Adjust in increments of
5 microgram/kg/hr according
to response
l
l
l
l
l
l
Aged 12 months:
25 microgram/kg 6 hrly
Aged 36 months:
50 microgram/kg 6 hrly
Aged 712 months:
100 microgram/kg 4 hrly
Monitoring
l
l
l
l
Pain score
Sedation score
Respiratory rate, maintain:
if aged <6-months,
>20 breaths/min
l if aged 6-months,
>16 breaths/min
l if rate reduced, contact
medical staff
l SpO2 as appropriate
Hourly observations
l Pain score
l Sedation score
l Respiratory rate (as above)
l SpO2 monitoring
l Syringe movement
l Site for infection
l Urinary retention
Pain score
Sedation score
Respiratory rate (as above)
SpO2 as appropriate
Issue 4
Issued: November 2010
Expires: November 2012
SEDATION 1/2
ASSESSMENT
Sedation and anaesthesia belong to the
same spectrum of impaired
consciousness
l In sedation, patient maintains the
following vital functions without
assistance:
l protection of airway, swallowing,
cough reflex
l respiration
l cardiovascular stability
Cautions
Discuss with anaesthetist before
sedation if any of following present:
l Abnormal airway (including large
tonsils)
l Sleep apnoea
l Respiratory failure
l Respiratory disease with significant
functional compromise
l Active respiratory tract infection
l Cardiac failure
l Raised intracranial pressure
l Decreased conscious level
l Neuromuscular disease
l Bowel obstruction
l Significant gastro-oesophageal reflux
l Renal impairment
l Liver impairment
l Previous adverse reaction to sedation
l Very distressed child
Potential difficulties
Sedation can be difficult in children:
l Taking anti-epileptics (can result in
increased or reduced effect of
sedating drug)
l Already taking sedating drugs
l With behavioural difficulties
Issue 4
Issued: November 2010
Expires: November 2012
l Portable oxygen
l Portable suction
l Appropriately sized face mask and
self-inflating resuscitation bag
27
SEDATION 2/2
SEDATION DRUG CHOICE
Drug
Chloral
hydrate
Route
l Oral
l Rectal
Melatonin
l Oral
Temazepam l Oral
Midazolam l Oral
Onset
Duration Dose
Comments Night
30 min1 hr 1-2 hr
l Night sedation
l more efficacious in
30 mg/kg
infants <15 kg or aged
l Pre-anaesthesia
<18 months
50 mg/kg
l Scans 70 mg/kg
l Maximum dose 2 g
l use for sedation before
l Aged 5 yr: 5 mg
1530 min 2-5 hr
EEG
l Aged >5 yr: 10 mg
l use 5 mg initially, if no
response, give further
5 mg
l 0.5 mg/kg
l CT, MAG3 scan
4590 min up to
l Up to 1 mg/kg for
4 hr
scans
l Max 30 mg
1530 min 12 hr
l Rectal
l Buccal
l IV
IV 23 min
l Nebuliser
Morphine
l Oral
15 min
sulphate
23 hr
MONITORING
l Keep under direct observation
l Once asleep or if <1 yr, monitor
saturation continuously
l Record saturation, heart rate and
colour every 15 min
l Discontinue once conscious level
returned to normal
SUBSEQUENT MANAGEMENT
Failed sedation
28
l Oral: 500
microgram/kg (max
20 mg) aged 1
month18 yr
l Rectal: 300500
microgram/kg
l Buccal:
l aged 6 months
10 yr: 200300
microgram/
kg (max 5 mg)
l aged >10 yr: 67 mg
l IV: 2550 microgram/
kg (max 6 mg aged
1 month6 yr; max
10 mg aged 612 yr;
max 7.5 mg aged
1218 yr)
l IV cannulation
(+EMLA or local
anaesthetic)
l more suitable for older
children
l not for CT scan
l repeat
100 microgram/kg IV
if necessary up to max
5 mg
l 200400
microgram/kg for
children >1 yr
l Max 20 mg
Paradoxical excitement
Issue 4
Issued: November 2010
Expires: November 2012
Heparin is potentially a
dangerous drug. Higher
strengths of heparin given
regularly to small babies could
lead to full anticoagulation.
Ensure that the correct strength
of heparin is prescribed. Do not
use heparin if any history of an
adverse reaction to it, e.g.
heparin induced
thrombocytopenia
PERIPHERAL IV CANNULAE
Flushing volume
l 3 mL
Intermittent administration of
drugs
PERIPHERALLY INSERTED
LONG VENOUS CATHETER
(long line)
Continuous infusion in progress
l No flush required
Intermittent administration of
drugs within a 24 hr period
l Flush with sodium chloride 0.9% 5 mL
injection before drug administration
l Flush with heparin 10 units/mL 5 mL
after drug
Not in use
Continuous infusion in
progress
l No flush required
Intermittent administration of
drugs within a 24 hr period
l Flush with sodium chloride 0.9% 1 mL
injection before the drug, and sodium
chloride 0.9% 3 mL injection after
drug administration
29
Not in use
l Flush daily via appropriate injection
membrane or needle-free device with
sodium chloride 0.9% 1 mL injection
followed by 2 mL heparin 10 units/mL
in sodium chloride 0.9% injection
Notes
l If additional extensions or ancillary
equipment are attached to catheter,
increase flushing volumes to take
account of extra volume of this
equipment. Exceed total volume
calculated by 0.5 mL
l Treat each lumen of catheter
separately
Hickman 10 Fr
Hickman 10 Fr
Intermittent administration of
drugs within a 12 hr period in
hospital
l Flush with sodium chloride 0.9%
injection before and after drug
administration via lumen, appropriate
injection membrane or needle-free
device
30
Intermittent administration of
drugs >12 hr apart in hospital
l Discard 3 mL before drug
administration
Intermittent administration of
drugs within a 24 hr period in
the community
l Flush with sodium chloride 0.9%
injection before and after drug
administration and then flush with
heparin 10 units/mL in sodium
chloride 0.9% injection via lumen,
appropriate injection membrane or
needle-free device
Not in use
l Flush once weekly with 5 mL heparin
10 units/mL in sodium chloride 0.9%
injection. Always inject 0.5 mL more
of heparin solution than the volume of
the catheter plus the volume of
attached equipment e.g. one-way tap,
short extension
IMPLANTABLE PORT
(e.g. Portacath)
Continuous infusion in progress
l No flush required
Intermittent administration of
drugs
l Flush with sodium chloride 0.9%
10 mL injection before and after drug
administration and then flush with
5 mL heparin 10 units/mL in sodium
chloride 0.9% injection. After the last
intravenous dose of a course of
treatment, flush with sodium chloride
0.9% 5 mL injection followed by 5 mL
heparin 100 units/mL (e.g. Canusal
not Hepsal)
Not in use
l Flush monthly with sodium chloride
0.9% 5 mL injection followed by 4 mL
heparin 100 units/mL in sodium
chloride 0.9% injection
Insertion flush
l Flush with sodium chloride 0.9%
injection during procedure. At end of
procedure, lock with 2.5 mL heparin
100 units/mL in sodium chloride 0.9%
injection
GROSHONG CENTRAL
VENOUS CATHETER
l This special catheter has a slit valve
at the tip to prevent backflow of blood
into catheter. Heparin is not required
to maintain patency and sodium
chloride 0.9% should be used for
flushing (manufacturer recommends
sodium chloride 0.9% 5 mL injection
once weekly)
CENTRAL VENOUS
HAEMODIALYSIS CATHETERS
l Use heparin 100 units/mL in sodium
chloride 0.9% injection for heparin lock,
volume dependent on catheter size
Issue 4
Issued: November 2010
Expires: November 2012
31
Symptomatic
hyponatraemia
is a medical
emergency
100 mL/kg/day
50 mL/kg/day
20 mL/kg/day
Patients requiring both maintenance fluids and replacement of ongoing losses should receive a single isotonic
fluid such as sodium chloride 0.9% with potassium 0.15% or sodium chloride 0.9% with glucose 5%
Monitoring
Weigh patient before starting fluid therapy, then daily if possible
Check plasma electrolytes before commencing infusion, except before majority of elective surgery
Check plasma electrolytes every 24 hr whilst intravenous fluids are being administered
if abnormal or if plasma sodium <130mmol/L measure every 46 hr
Check plasma electrolytes immediately if clinical features suggestive of hyponatraemia; features include nausea,
vomiting, headache, irritability, altered level of consciousness, seizure or apnoea
Maintain fluid balance chart to record input and output. Oliguria may be due to inadequate fluid, renal failure,
obstruction or effect of ADH
Some acutely ill children with increased ADH secretion may benefit from restriction of maintenance fluids to 2/3 of
normal recommended volume
Contact senior paediatrician, PICU or paediatric anaesthetist if uncertain or ongoing fluid losses
l infusion equipment
l site of infusion
l Close all clamps and switch off pump before removing giving set
32
Issue 4
Issued: November 2010
Expires: November 2012
PROCEDURE
PIC Line preparation
EQUIPMENT
l Assistant
l Long line several types are in
common use: choose widest bore
possible
l Vygon PICC 3, 4 or 4.5 F 60 cm
Lifecath (Expert silver coated)
l Vygon Nutriline 2, 3 or 4 F 30 cm
l Leaderflex 22G (2.5 F) line 8 or 20 cm
l Vygon Neocath or Epicutaneo-cave
catheter 2 F (23G) 15, 30 or 50 cm
has different insertion technique, not
recommended except neonates
33
Aseptic technique
l Wash hands, and put on apron/gown
and sterile gloves
l Clean patients skin thoroughly with
alcoholic chlorhexidine and allow to
dry in area of planned insertion
l Drape sterile sheet to expose only
chosen vein, and cover surrounding
areas to provide working room and a
flat surface on which to rest your line,
forceps and flush
34
Issue 4
Issued: November 2010
Expires: November 2012
35
PROCEDURE
All children aged 1 yr
Morning operating lists
l No solid food after midnight
l Allow clear fluids (e.g. water or fruit
juice) according to appetite, to finish
before 0700 hr
36
Issue 4
Issued: November 2010
Expires: November 2012
MANAGEMENT
Pre-operative
l Check haemoglobin
Subsequent post-GA
management
l High dependency nursing care
l Monitoring to include:
Issue 4
Issued: November 2010
Expires: November 2012
37
Breathlessness
Wheeze
Cough
Nocturnal cough
Tight chest
Bilateral wheeze
Symptoms and signs tend to be:
variable
intermittent
worse at night
provoked by triggers, including
exercise
Mild/moderate
l Normal vital signs
l Mild wheeze
l Speaks in complete sentences or
feeding
l SpO2 >92% in air
l PEF >75% in patient aged 7 yr
Severe
l Too breathless to talk/feed
l Tachypnoea (>50 breaths/min if aged
<5 yr; >30 breaths/min if aged >5 yr)
l Tachycardia (>130 beats/min if aged
<5 yr; >120 beats/min if aged >5 yr)
l Use of accessory muscles, recession
subcostal and intercostal, flaring of
alae nasi
l SpO2 <92% in air
l Peak expiratory flow (PEF) 50%
predicted/best
Life threatening
l Cyanosis/pallor
l Decreased air entry/silent chest
l Poor respiratory effort
38
Foreign body
Pneumonia
Pneumothorax
Aspiration
Cystic fibrosis
Tracheobronchomalacia
Gastro-oesophageal reflux
Investigations
l
l
l
l
l
l
Record:
respiratory rate
heart rate
air entry
O2 saturation in air
if aged 7 yr, peak expiratory flow
(PEF)
l conscious level
Senior assessment
If you are worried about childs conscious
level or there is no response to nebulised
salbutamol or poor respiratory effort:
l Call senior doctors for further
assessment
Issue 4
Issued: November 2010
Expires: November 2012
Not responding
Monitoring
l Record heart rate and respiratory rate
every 10 min
l Continuous SpO2
l Cardiac monitoring
l Baseline U&Es (capillary blood gas
for potassium)
SUBSEQUENT MANAGEMENT
Follow the algorithm Management of
acute wheezing
Previous history
l Salbutamol 2 microgram/kg/min
continuous infusion
l use 1 mg/mL solution for IV infusion
dilute 10 mg (10 mL) to concentration
of 200 microgram/mL made up to
50 mL with sodium chloride 0.9%
l If not responding increase to
5 microgram/kg/min for 1 hr then
reduce back to 2 microgram/kg/min
l If requiring >2 microgram/kg/min
admit to PICU
l Use TcCO2 monitor
l Continue with high flow O2 and
continuous salbutamol nebuliser while
waiting
Drug doses
Discharge criteria
l SpO2 in air >92%
l Respiratory rate: <50/min aged <5 yr;
<30/min aged >5 yr
l Heart rate: <130/min aged <5 yr;
<120/min aged >5 yr
l Peak flow: 75% predicted/best
l Stable on 4 hrly treatment
39
Discharge treatment
l Prescribe beta-agonist with spacer
l Give prednisolone 0.5 mg/kg daily for
35 days
l Educate on use of PEF meter if aged
>6 yr (not if child has never used one
before)
l Follow-up in either nurse-led asthma
clinic (if available) or consultant clinic
40
Chronic management
l Give inhaled corticosteroid if any of
following:
l frequent episodes
l bronchodilators used most days
l nocturnal and/or exercise-induced
symptoms
l other atopic symptoms and strong
family history of atopy
l If recurrent upper respiratory tract
problems or allergic rhinitis triggering
attacks, give steroid nasal spray
Issue 4
Issued: November 2010
Expires: November 2012
Reassess
1530 min
SEVERE
ADMIT
l Continue high flow O2
via mask or nasal
cannula
l Nebulised salbutamol
15 min4 hrly
l If poor response repeat
ipratropium bromide
every 2030 min for
first 2 hr
LIFE THREATENING
Reassess
Symptoms
improving
l Continuous nebulised
salbutamol
l IV salbutamol (see
Immediate treatment)
l Blood gases
l Chest X-ray
Re-assess frequency of
bronchodilator therapy
Symptoms
improving
No change/
worsening
No
improvement
No improvement
41
BRONCHIOLITIS 1/3
RECOGNITION AND
ASSESSMENT
Definition
l Acute inflammatory illness of small
airways that occurs in winter
epidemics and affects children aged
<2 yr, with peak incidence at around
6 months
l Respiratory syncytial virus (RSV) is
causative agent in >50% of cases,
with parainfluenza 3, influenza and
adenovirus types 3, 7 and 21 causing
the remainder
Differential diagnosis
l Recurrent viral-induced wheeze
l Early asthma
l Cystic fibrosis
l Pertussis
l Recurrent aspiration
l Foreign body in trachea
l Congenital lung anomaly
42
Investigations
l SpO2 while breathing air
l If respiratory rate >80 breaths/min,
transcutaneous PCO2 >6 kPa, SpO2
<92% in >50% inspired oxygen or
severe respiratory distress, measure
arterial or capillary blood gases
l Avoid tests that do not contribute to
immediate management. Perform
following only for specific indications:
l viral throat swab for RSV and
influenza if admission required for
oseltamivir if H1N1
l nasopharyngeal aspirate for
respiratory virus immunofluorescence
in severely immunocompromised
patient to plan antiviral treatment
l chest X-ray if there are localising
signs, cardiac murmur or atypical
presentation (e.g. aged >18 months)
l U&E if there is a plan for IV fluids
l blood cultures if signs of sepsis or
temperature >38.5C
IMMEDIATE TREATMENT
l Nurse in cubicle, or in bay with
children with same proven diagnosis
l Strict hand washing to support
infection control and use apron for
patient contact
l Nurse head up to reduce splinting of
diaphragm
l Clear airway by suction of nares and
mouth
l Use sodium chloride 0.9% nose drops
before suction
Respiratory
l If O2 saturation 92% in air, give O2
via face mask with a reservoir bag
l humidify oxygen
l if mask not tolerated, use nasal
prongs for oxygen flow up to 1 L/min
in children 5 kg body weight or up to
2.0 L/min in children >5 kg
Issue 4
Issued: November 2010
Expires: November 2012
BRONCHIOLITIS 2/3
Feeds
l Normal feeds (breast, bottle, solids) if
tolerated
l NG tube feeds if:
l oral intake by normal route insufficient
and
l airway protective reflexes test normal
on suctioning
and
l patient well enough to tolerate NG
feeds
l IV fluids (as above) if:
Issue 4
Issued: November 2010
Expires: November 2012
Drug treatment
l In immunocompetent patients, drug
treatment and physiotherapy (in acute
phase) are ineffective. DO NOT
ROUTINELY PRESCRIBE
bronchodilators, antibiotics or steroids
l In severely immunocompromised
patient, request consultant approval
before prescribing ribavirin
l For babies aged <6 weeks or patients
with temperature >39C, discuss
antibiotics with consultant
l If symptoms <48 hr and influenza test
positive or high prevalence influenza
(see www.hpa.org.uk) and risk factors
(chronic respiratory, renal, liver,
neurological or cardiovascular disease,
diabetic or immunocompromised) give
oseltamivir
43
BRONCHIOLITIS 3/3
Relative
l Re-attends A&E in <48 hr
l Aged <6 weeks (corrected gestational
age)
l Unsatisfactory family circumstances
and impaired ability to care for unwell
child
l Younger children (i.e. aged
<6 months), presenting earlier in
illness (<3 days symptoms)
l Pre-existing lung disease, including
chronic lung disease, ex-preterm,
cystic fibrosis: inform speciality
consultant
l Other pre-existing chronic disease
for example neurodegenerative
MONITORING TREATMENT
l Standard nursing observations
l Continuous O2, saturation monitoring
if patient requires supplemental O2
44
SUBSEQUENT MANAGEMENT
l Nurse in cubicle, or in bay with
children with same proven diagnosis
l Strict hand washing to support
infection control and use apron for
patient contact
l Fluid balance
l Oxygen support:
l test the need for support 6 hrly
l keep oxygen saturation 92% in
recovery phase
l wean from nasal prongs to air as
tolerated
Issue 4
Issued: November 2010
Expires: November 2012
CROUP 1/2
DEFINITION
CROUP
Aetiology
l Aged 6 months6 yr (peak age 2 yr)
l Seasonal peak: Spring and Autumn
l Transmission: usually by droplet
spread
l Incubation period 26 days
STRIDOR
Assessment
l Inspiratory stridor
Assessment
l Record croup severity:
l C Cyanosis
l R Recession of chest
l On crying/exertion
l Severe/biphasic
l heart rate
l At rest
l level of consciousness
Severity
Mild croup
l Barking cough
Chronic
l Allergic airways disease (recurrent
croup)
l Congenital abnormality
l Laryngomalacia
l Foreign body
l respiratory rate
l Nil/intermittent stridor
l No recession
l No cyanosis
Moderate croup
l Stridor at rest
l Mild recession
Issue 4
Issued: November 2010
Expires: November 2012
45
CROUP 2/2
Severe croup
l Stridor at rest
l Cyanosis
Investigations
l No investigations necessary, do not
attempt to take blood or put in cannula
l If diagnosis unclear, or child severely
unwell, call consultant as an
emergency measure
IMMEDIATE MANAGEMENT
Mild to moderate croup
l Antipyretics
l Oral dexamethasone
150 micrograms/kg, can be repeated
12 hr later if symptoms persist
l Admit/observe for 4 hr and reassess
l Oral dexamethasone
150 micrograms/kg (or if child refuses
to swallow oral medication, nebulised
budesonide 2 mg)
l High flow oxygen 15 L/min via mask
with reservoir bag
l laboured breathing
l persistent fever
l biphasic/worsening stridor
l cyanosis
l reduced level of
consciousness/confusion
l No follow-up
Severe croup
l Keep child and parents calm: do not
upset child e.g. by forcing oxygen
mask onto face or examining throat;
nurse on parents lap and in position
they find comfortable
l Nebulised adrenaline
400 micrograms/kg to max 5 mg
(0.4 mL/kg to max 5 mL 1:1000)
relieves symptoms, but short
duration of action
46
Issue 4
Issued: November 2010
Expires: November 2012
ADMISSION PROCEDURE
l Plot baseline weight, height
l Perform flow volume loop spirometry
on admission day (aged >67 yr)
l Write up drug chart before parents
leave
l Check whether annual bloods could
conveniently be taken now (see
Annual bloods)
l Ask nursing staff to inform
physiotherapist and dietitian on day of
admission
l Check specific aspects of
management or investigations, as
described by CF team
l for IV antibiotics, see Cystic fibrosis
Exacerbation guideline
l for bowel blockage, see Cystic fibrosis
Distal intestinal obstructive
syndrome (DIOS) guideline
INVESTIGATIONS
Annual bloods
l All children attending CF clinics have
annual blood screening
l Perform annual bloods if admission
within a month of annual screening
(usually at time of birthday):
l during insertion of a long line or Porta-cath needle
l when taking tobramycin levels
All ages
l FBC and film
l Vitamins A, D, E
l Parathyroid hormone
l U&E, creatinine, chloride, calcium,
magnesium, phosphate, albumin, total
protein, alkaline phosphatase,
bilirubin, AST/ALT, GGT, CRP
l Glucose
Issue 4
Issued: November 2010
Expires: November 2012
If aged >5 yr
All of the above plus:
l If symptoms could be caused by
allergic bronchopulmonary
aspergillosis, specific IgE to
aspergillus and aspergillus precipitins
l If diabetic, HbA1c
If aged 10 yr
Chest X-ray
l Most children have chest X-ray every
612 months so another may not be
necessary
l Check when latest was taken and, if
in doubt, discuss with CF consultant
Microbiology
l In hospital, request twice weekly
sputum/cough swab
l usually performed by physiotherapist
but check this has been done
l If new pathogen found, see Cystic
fibrosis Microbiology guideline
and cross-infection
47
NUTRITION
l Involve dietitians closely
l Weigh twice weekly, in nightwear and
before breakfast (weigh babies
naked if possible)
l Continue normal supplements
l Infants
l Creon Micro for children 1/2 scoop
(2500 units lipase) to 1 scoop
(5000 units lipase) per 120 mL milk or
breast feed
OR
l Creon 10,000 one-quarter (2500 units
lipase) to one-half capsule (5000 units
lipase)/120 mL milk or breast feed
Signs of malabsorption
l Fatty pale stools, frequent, smelly,
orange oil, excess flatulence,
abdominal pains
l discuss with CF team
H2-receptor antagonists
l If taking large doses of pancreatic
enzymes (e.g. >10,000 units lipase),
discuss with CF team need for
concurrent ranitidine to reduce
deactivation of pancreatin
Vitamins A, D and E
Starting dosage for newly-diagnosed
l Infants
l 0.6 mL Dalivit or/and 0.5 mL (50 mg)
Vitamin E
l Children
l 1.2 mL Dalivit or 3 BPC
multivitamins capsules and 100 mg
Vitamin E (2 x 50 mg capsule)
OR
l continue dose as prescribed in CF
clinic
l Vitamin levels are checked annually
and dosage adjusted accordingly
l Children
l starting dose Creon 10,000 2 capsules
per meal, 1 capsule per snack
48
Issue 4
Issued: November 2010
Expires: November 2012
Investigations
l See investigations in Cystic fibrosis
Admission guideline
Differential diagnosis
l Non-CF bronchiectasis
l Chronic obliterative bronchiolitis
ADDITIONAL ADMISSION
PROCEDURE
l If IV antibiotics required, discuss with
CF team re procedure:
IMMEDIATE TREATMENT
l Use IV antibiotic regimen suggested
following discussion with CF team
First-line regimen
l Sputum culture
l Pseudomonas aeruginosa: ceftazidime
50 mg/kg 8 hrly (max 9 g/day) and
tobramycin 10 mg/kg once daily (max
660 mg) given over 30 min (if
converting from 8 hrly to once daily,
use previous total daily dose)
l no Pseudomonas aeruginosa:
cefuroxime 50 mg/kg 8 hrly (max 1.5 g)
Nebulised antibiotics
l Give children colonised with
Pseudomonas, colomycin 1 million
units made up to 4 mL with sodium
chloride 0.9%, nebulised 12 hrly
Oral antibiotics
l Children are rarely given oral
antibiotics during admission but may
resume an oral agent on discharge
Bronchodilators
l Prescribe salbutamol by MDI and
spacer 8 hrly before chest
physiotherapy in hospital
Inhaled corticosteroids
l There is no evidence these are of
benefit. Discuss with CF team re
stopping
49
SUBSEQUENT MANAGEMENT
l Do not change antibiotics before
discussing with CF team
Oral corticosteroids
l If no chest improvement after a week
of IV antibiotics, consider starting 7 day
course of prednisolone 1 mg/kg/day
l If already taking alternate-day
prednisolone at lower dosage, review
dosage needed at discharge
l For children with allergic
bronchopulmonary aspergillosis
(ABPA), continue prednisolone for
longer (e.g. at least one month)
50
Self-administration of IV
antibiotics home IV therapy
Issue 4
Issued: November 2010
Expires: November 2012
PSEUDOMONAS AERUGINOSA
Nebulised antibiotics
l If colonised with Pseudomonas, give
colomycin 1 million units made up to
4 mL with sodium chloride 0.9%,
nebulised 12 hrly
l Tobramycin, decided by CF team
BURKHOLDERIA CEPACIA
COLONISATION
l Report any new cases to CF team
l Nurse children with B. cepacia
colonisation in a cubicle on a
separate ward from other CF children
l Use separate spirometer with
disposable filters
MRSA COLONISATION
l Report any new cases to CF team
l Use normal spirometer with a
disposable filter
CHICKENPOX AND CF
First isolations in sputum or
cough/throat swabs
l If asymptomatic with first isolation
from sputum/cough swab:
l ciprofloxacin aged 1 month1 yr
15 mg/kg, aged >1 yr 20 mg/kg (max
750 mg) 12 hrly orally and colomycin
aged <2 yr 1 million units 12 hrly and
aged 2 yr 2 million units 12 hrly via
nebuliser for 3 months
l If asymptomatic with recurrent
isolation from sputum/cough swab:
l ciprofloxacin and colomycin
l If symptomatic:
l tobramycin and ceftazidime
(according to sensitivities) IV for 2
weeks, and on discharge from
hospital: ciprofloxacin and colomycin
Pseudomonas colonisation
Exposure
l Ask about exposure to a known case:
l being in the same room (e.g. in the
house, classroom or hall in school) for
15 min
l face-to-face contact, for example
whilst having a conversation
l If exposure significant, check notes to
determine immune status (history of
chickenpox or antibody status before
corticosteroids)
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Infected
l If chickenpox appears in a child not
taking oral corticosteroid, give oral
aciclovir (20 mg/kg/dose aged
<12 yr 6 hrly, aged >12 yr 5 times/day,
max 800 mg/dose) for 7 days and a
course of oral antibiotics (e.g.
amoxicillin and flucloxacillin) as for
acute exacerbation
PORT-A-CATH
l Use in children requiring frequent IV
antibiotics
l Manufacturer's instructions found on
ward
l Observe sterile precautions whenever
Vascuport accessed
l accessed only by trained nursing staff
INFLUENZA AND
PNEUMOCOCCAL VACCINE
l Influenza vaccine every October
l follow advice on any current
pandemic flu
l Conjugate pneumococcal vaccine
(Prevenar 13)
l For all children with CF
l Usually prescribed by patients own
GP but obtainable from pharmacy
52
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MANAGEMENT
l If symptoms very mild, prescribe daily
macrogol laxative (e.g. Movicol) and
encourage fluids
l Consider adjusting pancreatic
enzymes
l If unresponsive, or symptoms more
severe, proceed as follows:
single dose of Gastrografin:
aged 1 month2 yr: 1530 mL
1525 kg 50 mL
>25 kg 100 mL
l repeat dose after 1218 hr,
encourage drinks, monitor fluid
balance and allow food
l If no effect after 2448 hr or if patient
deteriorates, give balanced electrolyte
solution:
l bowel lavage with Kleen-Prep or
Golytely (usually requires a
nasogastric tube)
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53
PNEUMONIA 1/3
If aged <1 month-old, refer to
Neonatal guidelines
Investigations
RECOGNITION AND
ASSESSMENT
Definition
l Inflammation and consolidation of the
lung caused by a bacterial, viral or
mycoplasma infection
l Absence of clinical signs AND
negative CXR makes pneumonia
unlikely
l Pulse oximetry
l CXR
l Cough
l Fever
l Irritability
Differential diagnosis
l Poor feeding
l Vomiting
IMMEDIATE TREATMENT
Table 1: WHO definition of tachypnoea
Age
<2 months
211 months
15 yr
See flowchart 1
Pleural effusion
l See Pleural effusion guideline
54
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PNEUMONIA 2/3
SUBSEQUENT MANAGEMENT
l If atypical or staphylococcal
pneumonia, treat for 14 days
uncomplicated CAP and 1421 days
for severe CAP
l lobar collapse
MONITORING TREATMENT
l Continuous SpO2 monitoring if
needing O2
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PNEUMONIA 3/3
Flowchart 1: Management of community acquired pneumonia in a previously
well patient aged >1 month-old
ANY of following apply:
l Aged <3 months
l SpO2 <92% in air
l Intermittent apnoea/grunting
l Tachypnoeic
l Pleural effusion
l Very unwell*
l
l
l
l
NO
YES
Admit to hospital
l Poor perfusion
l Altered level of consciousness
l Respiratory failure: hypoxia,
hypercapnia, acidosis
l Resuscitate
l Discuss case with PICU
NO
Pleural effusion?
YES
l Oral amoxicillin
l If vomiting or severe
symptoms, IV co-amoxiclav +
clarithromycin
l FBC, U&E
l Fluid balance/observations
**Mycoplasma pneumonia
suggested by:
l Aged >5 yr
l Subacute onset
l Prominent cough
l +/- headache
l +/- sore throat
YES
YES
Aspiration
YES
Hospital acquired
Improves in 24-48 hr
YES
NO
56
YES
Add metronidazole
Change to piperacillin/tazobactam
l
l
l
l
Discharge
Change from IV to oral antibiotics
Total antibiotic course for 57 days
Follow up within 68 weeks. See
Discharge and follow-up
Change to meropenem
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Definition
l A collection of fluid in pleural space,
for example:
l parapneumonic effusion pleural fluid
collection in association with
underlying pneumonia
l empyema presence of pus in
pleural cavity
Differential diagnosis
l Uncomplicated pneumonia
l Malignancy
l Effusion with alternative cause (e.g.
congestive cardiac failure,
pancreatitis)
l Pulmonary embolism
Investigations
l Chest X-ray
l Ultrasound (US) scan to:
l confirm presence of effusion
l ascertain volume
l indicate optimal position for chest
drain
l differentiate between simple and
complicated effusion (e.g. loculations,
heterogeneous material)
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Transudate
Serous
<10,000/mm3
30 g/L
0.5
200 IU
0.6
3.3 mmol/L
7.4
No organisms
IMMEDIATE TREATMENT
Supportive
l ABC
l O2 and fluid resuscitation as indicated
l Analgesia
Exudate
Cloudy, bloody
>50,000/mm3
>30 g/L
>0.5
>200 IU or >2/3 local upper limit of serum LDH
>0.6
<3.3 mmol/L
7.3
Organisms on stain or culture
Refer to respiratory
paediatrician
l Remember that underlying cavitating
disease may lead to bronchopleural
fistulae. Assess likelihood of this
problem before inserting any chest
drain
Antibiotic therapy
Type of effusion suspected
Effusion following community-acquired
pneumonia
Effusion following hospital-acquired
pneumonia or in immune-compromised child
Effusion possibly tuberculous
58
Choice of antibiotics
IV co-amoxiclav
Discuss with respiratory paediatrician
Discuss with specialist
Intrapleural fibrinolytics
l Instill urokinase in all patients, as
follows:
SUBSEQUENT MANAGEMENT
Act on response to treatment and
clinical assessment of patient
Non-resolution
l Non-resolution of effusion after 3
days or further complications occur,
consider CT scan of chest
Surgery
l Discuss with paediatric thoracic
surgeon if:
l effusion has not resolved
l child is clinically unwell
59
PNEUMOTHORAX 1/2
Spontaneous pneumothorax
RECOGNITION AND
ASSESSMENT
Symptoms and signs
Tension pneumothorax
(very rare)
l Severe dyspnoea
l Circulatory compromise
l Trachea +/- apex beat displaced
Treat immediately:
l Give O2 15 L/min with mask with
reservoir bag
l Insert a large bore cannula of at least
4.5 cm in length into 2nd anterior
intercostal space, midclavicular line
l Insert intercostal tube
l Remove emergency cannula when
bubbling in underwater seal system
confirms intercostal tube system
functioning
Investigation
l PA chest X-ray
l If findings are unclear on PA, lateral
(if possible, decubitus) film may help
l If findings obscured by surgical
emphysema or complex bulla disease,
CT scan may help
IMMEDIATE TREATMENT
Chest X-ray
Large collapse
Rim of air 2 cm
Small collapse
Rim of air <2 cm
Significant dyspnoea
Yes
Aspirate
Successful?
(asymptomatic)
No
No
Chronic lung
disease
No
Intercostal
tube drainage
Yes
Observe for 4 hr
Follow-up
60
No
Yes
In-patient
observation
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PNEUMOTHORAX 2/2
Management of intercostal drains
X-ray next morning
Yes
Still bubbling?
No
Re-expanded?
Yes
Yes
No
No
Wait 24 hr
If no bubbling remove drain 2
Repeat X-ray
Collapsed again?
Yes
No
Follow-up 4
Respiratory opinion 5
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l 4: Follow-up:
l at clinic in 710 days
l patient given discharge letter and
written advice to return immediately if
deteriorates
l no air travel until chest X-ray resolved
l 5: Respiratory paediatricians
opinion:
l why no re-expansion (e.g. air leak,
displaced/blocked tube, bronchopleural fistula, underlying pulmonary
disease)?
l use of high volume/low pressure
suction, 12 kPa/Barr, (816 mmHg;
820 cm H2O)
61
Duct-dependent pulmonary
circulation
l Commonly presents in first
1014 days of life
l severely blue, breathless or shocked
l pulmonary atresia
l critical pulmonary valve stenosis
l tricuspid atresia
62
Physical examination
l Remember to check femoral pulses
l If coarctation of the aorta suspected:
check BP in upper and lower limbs
normal difference <15 mmHg
Investigations
If infant cyanosed or in heart
failure, discuss urgency of
investigations with consultant
SpO2
Chest X-ray
l For cardiac conditions, specifically
record:
l cardiac situs (normal or right side of
chest)
l aortic arch left or right-sided
l bronchial situs (is right main bronchus
on the right?)
l cardiac size and configuration
l size of pulmonary vessels and
pulmonary vascular markings
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Echocardiogram
SUBSEQUENT MANAGEMENT
IMMEDIATE TREATMENT
If infant cyanosed or in heart
failure, discuss urgency of
referral to local paediatric
cardiac surgical centre with
consultant
Duct-dependent congenital
heart disease
l Immediate treatment before transfer
to a paediatric cardiac centre:
l open duct with Prostin [prostaglandin
E1 (alprostadil) or E2 (dinoprostone)
same dose]:
l 510 nanogram/kg/min IV infusion to
start
l increasing in steps of
510 nanogram/kg up to max
100 nanogram/kg/min
l then reducing to lowest dose needed
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RECOGNITION AND
ASSESSMENT
Presentation
l Usually during first few weeks of life
l Later triggered by an intercurrent
infection, with associated myocarditis
or prolonged arrhythmia
INVESTIGATIONS
SpO2
64
Chest X-ray
Electrocardiogram
l See ECG interpretation guideline
l Axis of QRS complex
l P-wave
l R-S pattern in chest leads
l P-R, QRS and Q-T intervals
l P- and T-wave configuration
l size of QRS in chest leads
Echocardiogram
Recognition of cardiogenic
shock
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MONITORING
l ECG monitor
l Non-invasive BP
l Pulse oximetry
l Core-skin temperature difference
l Daily weights
l Intra-arterial BP for continuous
pressure monitoring and arterial blood
gas sampling
l CVP: if shocked or 40 mL/kg fluid
resuscitation has been needed
l Urine output (1 mL/kg/hr)
THERAPEUTIC MEASURES
Progressive measures: 18 for all
patients; 911 if cardiogenic shock
1. If breathless, elevate head and trunk
2. If infant not feeding well, give
nasogastric feeds
3. In moderate-to-severe failure or if
patient hypoxic or distressed, give O2
therapy via nasal cannulae (up to
2 L/min) or via a face mask with
reservoir bag (up to 15 L/min)
4. Diuretics: furosemide 1 mg/kg orally
or by slow IV injection and amiloride
100 microgram/kg (max 10 mg) orally
12 hrly (doses can be repeated if not
responding to initial dose)
5. If serum potassium <4.5 mmol/L,
give additional potassium chloride
1 mmol/kg 12 hrly enterally
6. Correct acidosis, hypoglycaemia and
electrolyte imbalance
7. Relieve pain with morphine: loading
dose 100 microgram/kg slow IV,
followed by 50 microgram/kg slow IV
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DUCT-DEPENDENT
CONGENITAL HEART DISEASE
l May present in first two weeks of life
Duct-dependent systemic
circulation
l Breathless, grey, collapsed, poor
pulses
l severe coarctation of the aorta
l critical aortic stenosis
l hypoplastic left heart syndrome
Duct-dependent pulmonary
circulation
l Blue, breathless or shocked
l pulmonary atresia
l critical pulmonary valve stenosis
l tricuspid atresia
l severe Fallots tetralogy
l transposition of the great arteries
Treatment
l See Cyanotic congenital heart
disease guideline
65
Causes
P WAVE
l Reflects atrial activity
l Duration shorter than in adults
l infants: 0.040.07 sec
l adolescents: 0.060.1 sec
l Height 2.5 mm
l Varying P wave morphology may
indicate wandering atrial pacemaker
l Pulmonary hypertension
l Pulmonary stenosis
l Pulmonary atresia
l Tricuspid atresia
Causes
l Mitral valve disease
l LV obstruction and disease
P-R INTERVAL
l Atrial depolarization varies with age
and rate
<60
6099
100139
140180
>180
Prolonged interval
l Normal
l Myocarditis
l Ischaemia
l Drugs
l Hyperkalaemia
Short interval
l Wolff-Parkinson-White syndrome
l Lown-Ganong-Levine syndrome
l Glycogen storage disease
1216 yr
0.10.19
0.10.17
-
QRS COMPLEX
l Ventricular activity
l Duration: 0.060.08 sec
Prolonged
l Ventricular hypertrophy
l Bundle branch block
l Electrolyte disturbance
l Metabolic disease
l Drugs (e.g. digoxin)
Variable interval
l Wandering atrial pacemaker
l Wenckebach phenomenon
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Birth
6-12 months
1-10 yr
>10 yr
Q WAVE
l Normal in II; III; aVF; V5-6
l Depth 23 mm
l pathological if >4 mm (i.e. septal
hypertrophy)
l May be found in other leads in:
l anomalous coronary arteries
l hypertrophic obstructive
cardiomyopathy
l transposition of great arteries (with
opposite polarity)
Q-T INTERVAL
Inversely proportional to rate
l Calculate ratio of Q-T interval to R-R
interval
l QTc = Q-T
R-R1
l QTc is usually less than 0.44 s
l prolonged QTc is associated with
sudden death: alert consultant
immediately
Prolonged interval
l Hypocalcaemia
l Myocarditis
l Jervell-Lange-Nielsen syndrome
l Romano-Ward syndrome
l Head injuries or cerebrovascular
episodes
l Diffuse myocardial disease
l Antiarrhythmics
Short interval
l Hypercalcaemia
l Digitalis effect
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V6-R
113
525
525
530
V6-S
015
010
07
05
T WAVE
l Ventricular repolarization
Normal
l T inversion V4R/V1 (from third day of
life until 10 yr)
l Amplitude is 2530% of R-wave
l Aged <1 yr: V5 11 mm; V6 7 mm
l Aged >1 yr: V5 14 mm; V6 9 mm
l Adolescence reduces amplitude
Peaked T wave
l Hyperkalaemia
l LVH
l Cerebrovascular episode
l Post-MI
Flat T wave
l Normal newborn
l Hypothyroidism
l Hypokalaemia
l Hyper/hypoglycaemia
l Hypocalcaemia
l Peri/myocarditis
l Ischaemia
l Digoxin effect
67
Horizontal plane
(anterior chest leads)
Normal
l Transition at around V3
Clockwise rotation
l S>R in V4 = RA/RV hypertrophy
Anticlockwise rotation
l R>S in V2 = cardiac shift (e.g.
pneumothorax)
RIGHT VENTRICULAR
HYPERTROPHY
Diagnosis
l
l
l
l
l
l
l
l
l
Causes include
l Pulmonary stenosis/atresia
l Transposition of great arteries
l Pulmonary regurgitation
l Total anomalous pulmonary drainage
l Tricuspid regurgitation
l Fallot's tetralogy
l Pulmonary hypertension
LEFT VENTRICULAR
HYPERTROPHY
BIVENTRICULAR
HYPERTROPHY
Diagnosis
Diagnosis
l R + S >50 mm in V3-V4
l LVH + bifid R <8 mm in V1
l RVH + LV strain
l Q waves V3-V6 imply septal
hypertrophy
Causes include
l Aortic stenosis
l Aortic regurgitation
l Hypertension
l Moderate VSD
l Hypertrophic obstructive
cardiomyopathy
l Patent ductus arteriosus
l Mitral regurgitation
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ECG abnormalities
LVH > RVH; LAH
LVH > RVH; +/- RBBB; T inv LV. leads
Secundum RAD; RBBB; +/- increased P-R; AF
Primum
LAD; RBBB; BVH; RAH
RVH; P pulmonale
LVH + strain
LVH
Newborn:
RVH
Older:
Normal or LVH +/- strain; RBBB
LVH
RVH; RAH
Prolonged P-R interval; gross RAH; RBBB
Newborn:
Normal or T +ve V1
Older:
RVH; RAH
RAH
LAD; RAH; LVH
69
Investigations
l Confirm diagnosis with 12-lead ECG
l Continuous ECG monitoring is
essential
l Assess for cardiac failure
Differential diagnosis
l Sinus tachycardia, particularly in
infants, can be >200/min. However,
rates of 220300/min are more likely
to be SVT
l If first presentation, check for any
other cause of cardiac failure
70
Causes of tachyarrhythmias
l Re-entrant congenital conduction
pathway abnormality (common)
l Poisoning
l Metabolic disturbance
l After cardiac surgery
l Cardiomyopathy
l Long QT syndrome
ECG DIAGNOSIS
Infants
l Majority have a P wave before every
QRS complex, usually by >70 msec
(2 mm at 25 mm/sec)
l QRS complexes are generally normal
but may be wide
l Accessory pathway frequently
capable of anterograde as well as
retrograde conduction
l this will be revealed during normal
sinus rhythm by short P-R interval
and presence of a delta wave (classic
Wolff-Parkinson-White syndrome)
Older children
l Nodal tachycardias become more
common with increasing age
l characterised by fast, regular, narrow
QRS complexes without visible P
waves
l Wide QRS complex or bundle branch
block in childhood is rare
l changes also present in sinus rhythm
l review previous ECGs
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Vagal manoeuvres
These may include:
l Diving reflex
l wrap infants in a towel and immerse
their whole face into iced water for
about 510 sec
l in children, place a bag or rubber
glove containing iced water over face
l One side carotid massage
l Valsalva manoeuvre
l Where possible, maintain ECG
monitoring and recording during all
procedures
Other drugs
l If adenosine ineffective, seek advice
from a paediatric cardiologist
l In refractory Wolff-Parkinson-White
tachycardia, flecainide is particularly
useful
l In refractory atrial tachycardia,
amiodarone is useful
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71
Yes
No
Vagal manoeuvres
(if no delay)
Vagal manoeuvres
Adenosine
100 microgram/kg
Yes
Establish vascular
access if quicker
than obtaining defib
2 min
No
Adenosine
200 microgram/kg
2 min
Adenosine
300 microgram/kg
72
Synchronous DC shock
1 J/kg
Synchronous DC
2 J/kg shock
Amiodarone
Causes
l Underlying cause (e.g. myocarditis,
cardiomyopathy, or patient with
congenital heart disease)
l Poisoning (e.g. phenothiazines,
tricyclic antidepressants, quinidine
and procainamide)
l Electrolyte disturbance (e.g.
hypokalaemia, hypomagnesaemia)
l Ventricular tachycardia can
degenerate into ventricular fibrillation
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l Seek advice
l Ventricular tachycardia not always
obvious on ECG, clues are:
l rate varies between 120 and 250
beats/min (rarely 300 beats/min)
l QRS complexes are almost regular
though wide
l QRS axis abnormal for age (normal
for aged >6 months is <+90)
l no preceding P wave, or A-V
dissociation
l fusion beats (normally conducted
QRS complex merges with an
abnormal discharge)
IMMEDIATE TREATMENT
Ventricular tachycardia
VF protocol
No
Pulse present
An anaesthetic must be
given for DC shock if
patient responsive to
pain
Yes
Hypotensive
No
Yes
Amiodarone
5 mg/kg (max 300 mg)
over 30 min
Synchronous DC
shock
1 J/kg
Consider:
l synchronous DC shock
l seek advice
Synchronous DC
shock
2 J/kg
Amiodarone
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74
BRADYARRHYTHMIAS
l Urgently manage:
l pre-terminal event in hypoxia or shock
l raised intracranial pressure
l vagal stimulation
Investigations
l ECG to look for:
l conduction pathway damage after
cardiac surgery
l congenital heart block (rare)
l long QT syndrome
Management
l ABC approach: ensure adequate
oxygenation and ventilation
l If vagal stimulation is cause, give
atropine 20 micrograms/kg (min
100 micrograms; max 600 micrograms)
l Consider IV isoprenaline infusion
l Contact paediatric cardiologist for
advice
l fax ECG to cardiologist
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MANAGEMENT
l Patients at risk of endocarditis should
be:
l advised to maintain good oral hygiene
l told how to recognise signs of
infective endocarditis, and advised
when to seek expert advice
l Investigate promptly any infection in
patients at risk of endocarditis and
treat appropriately to reduce the risk
of endocarditis
l If patients at risk of endocarditis are
undergoing a gastro-intestinal or
genito-urinary tract procedure at a
site where infection suspected, give
appropriate antibacterial therapy that
includes cover against organisms that
cause endocarditis (see table)
Dose/route
Single dose IV
Aged <5 yr: 250 mg
Aged 59 yr: 500 mg
Aged 10 yr: 1 g
plus
plus
gentamicin
2 mg/kg IV single dose (120 mg aged 1018 yr)
If allergic to penicillin Single dose IV
Aged <14 yr: 6 mg/kg (max 400 mg)
teicoplanin
Aged 14 yr: 400 mg
plus
plus
2 mg/kg single dose IV
gentamicin
Comment
Give just before
procedure or at induction
of anaesthesia
The poisoners
l Most childhood poisonings are
accidental
l Intentional poisoning may be by the
child or an adult
l Inadvertent poisoning may occur in a
medical setting
The poison
l Children will eat and drink almost
anything
RECOGNITION AND
ASSESSMENT
Symptoms and signs
l Depressed respiration suggests
centrally-acting drug
l Skin blisters (between knees/toes)
common after barbiturates and tricyclics
l Hypothermia after exposure or
barbiturates
l Venepuncture marks and pinpoint
pupils suggest opioid overdose
l Burns around mouth
Life-threatening features
l Coma
l Cyanosis
l Hypotension
l Paralytic ileus
Quantity ingested
Investigations
l U&E
l Blood gases and acid-base
l Save blood and urine for toxicological
analysis. Urgent measurement of
plasma/serum concentrations
essential in diagnosis and
management of poisoning with
ethylene glycol, iron, lithium,
methanol, paracetamol, theophylline
and salicylate. With exception of
paracetamol, no need to measure
concentrations of these substances
unless clear history of ingestion
Neurological
l Control convulsions
l if unconscious, treat as head injury
until proved otherwise
Drug absorption
l Give antidote if appropriate
l Decrease absorption. Consider
gastric lavage only in patients whose
airway can be protected and who
have ingested life-threatening
amounts of a toxic agent up to 1 hr
previously, provided they are cooperative and have not ingested
petroleum distillates or corrosives
l If gastric lavage contraindicated,
consider activated charcoal in patients
who have ingested life-threatening
amounts of a toxic agent up to 1 hr
previously, provided patient conscious
or airway can be protected. Give 1 g/kg
(max 50 g) orally (disguised with soft
drink/fruit juice) or via nasogastric tube.
Activated charcoal does not affect
absorption of acids, alkalis, alcohols,
cyanide, ethylene glycol, iron or lithium
l Do not give ipecacuanha, it does not
empty the stomach reliably and can
be dangerous
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SUBSEQUENT MANAGEMENT
MONITORING TREATMENT
PSYCHIATRIC REVIEW
l Offer all patients admitted after
deliberate acute self-poisoning or
drug overdose an interview with the
psychiatric priority referral team within
24 hr of admission or regaining
consciousness
Severe toxicity
Potentially fatal
Alcoholic drinks/preparations
l Spirits are particularly dangerous
l Ask about alcopops
IMMEDIATE TREATMENT
l Ensure clear airway and adequate
ventilation
l Gut decontamination is unlikely to be
of benefit
l activated charcoal does not
significantly reduce rate of absorption
l Correct hypoglycaemia as quickly as
possible
l if awake, give oral glucose
l if drowsy or unconscious, give glucose
10% 5 mL/kg IV
l check blood glucose hourly until
consciousness regained
l Correct hypotension (see Poisoning
and drug overdose)
l Correct acid-base and metabolic
disturbance
l Correct hypothermia using conventional
means (e.g. Bair Hugger, blankets)
l Control convulsions with IV lorazepam
l If blood ethanol >5 g/L (108.5 mmol/L)
or if arterial pH <7.0, consider
haemodialysis
l discuss with National Poisons
Information Service (0844 892 0111)
78
INVESTIGATIONS
l Blood glucose
l In moderate to severe toxicity
l U&E
l arterial blood gases
l blood ethanol concentration
l 12-lead ECG
Assessment of severity
l Blood ethanol is a guide to severity of
poisoning
l <1.8 g/L (39 mmol/L) mild toxicity
l 1.83.5 g/L (3976 mmol/L) moderate
toxicity
l 3.54.5 g/L (7698 mmol/L) severe
toxicity
l >4.5 g/L (98 mmol/L) potentially fatal
l Observe for at least 4 hr if >0.4 mL/kg
body weight of absolute ethanol had
been ingested (i.e. 1 mL/kg 40% spirit,
4 mL/kg 10% wine or 8 mL/kg 5% beer)
l Monitor pulse, blood pressure and
body temperature
SUBSEQUENT MANAGEMENT
l See Poisoning and drug overdose
guideline
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)
Issue 4
Issued: November 2010
Expires: November 2012
Investigations
Assessment of severity
Review both clinical and
laboratory features
Action
l If clinical features and/or serum iron
concentration suggest severe toxicity,
contact National Poisons Information
Service (0844 892 0111) for advice
IMMEDIATE TREATMENT
Unconscious or in shock
l Assess airway, breathing, circulation
l Secure airway, treat shock, control
seizures
l IV fluids to replace losses
l Commence desferrioxamine IV (see
Desferrioxamine)
l if this is before time when serum iron
should be taken (4 hr), take sample
for serum iron immediately before
commencing desferrioxamine
l do not delay starting desferrioxamine
IV
l Gastric lavage only if ingested dose
>60 mg/kg and/or tablets seen on Xray and child presents within 1 hr
l do not use activated charcoal as it
does not adsorb iron
79
SUBSEQUENT MANAGEMENT
l See Poisoning and drug overdose
guideline
l If slow release preparations ingested,
repeat serum iron after further 68 hr
l In patients with severe toxicity:
l arterial blood gases and correct
acidosis
l If metabolic acidosis persists despite
correction of hypoxia and adequate
fluid resuscitation, give IV sodium
bicarbonate 1 mL/kg 8.4%
bicarbonate diluted in glucose 5% or
sodium chloride 0.9% 500 mL at
2-3 mL/kg/hr
l monitor renal and liver function
l be alert for evidence of gut
perforation or infarction
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)
Desferrioxamine
l Before starting treatment, contact
National Poisons Information Service
(0844 892 0111) for advice
l Starting dose is 15 mg/kg/hr
l Reduce after 46 hr
l maximum 80 mg/kg in 24 hr
l desferrioxamine commonly causes
hypotension if infused more rapidly
than recommended rate and turns
urine red/orange but rarely causes
rashes or anaphylactic reactions
80
Issue 4
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Expires: November 2012
Management for
l Paracetamol dose >12 g or 150 mg/kg
(>75 mg/kg in those at high risk)
l Symptomatic
l Or INR >1.3, ALT >150 IU/L,
abnormal acid/base or bicarbonate
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)*
l If there is absolute certainty that a
single dose of paracetamol of <12 g or
150 mg/kg (<6 g or 75 mg/kg in high
risk children) has been ingested,
plasma paracetamol need not be
measured and child requires no
treatment
Investigations
l Plasma paracetamol 416 hr after
overdose (but not before or after this
interval) is a reliable guide to the
need for treatment
Time from
overdose (hr)
<1
47
814
1524
Multiple/
staggered
overdose
>24
IMMEDIATE TREATMENT
l Compare plasma paracetamol with
treatment graph (Figure 1)
l use high risk treatment line for
patients who have existing liver
disease; are underweight with failure
to thrive, whatever the cause;
anorexia nervosa; cystic fibrosis; HIV
positive; and those taking enzymeinducing drugs (e.g. barbiturates,
phenytoin, carbamazepine, rifampicin,
St Johns Wort) or who chronically
abuse alcohol; they are at higher risk
of hepatic necrosis
l if above, on, or even slightly below
relevant treatment line, give IV
acetylcysteine in glucose 5%
l Time interval is critical in assessing
need for treatment. Detailed
questioning essential
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81
Aged <12 yr
with weight
>20 kg
Aged 12 yr
l
l
l
l
l
l
l
l
l
l Severe liver damage in the context of paracetamol poisoning has been defined as
a peak plasma ALT activity exceeding 1000 iu/L
Time of
presentation
after overdose
(hr)
<8
815
82
Monitoring/continued treatment
Discharge policy
Single IV dose
l INR, AST/ALT, creatinine,
l Discharge if INR 1.3, AST/ALT and
bicarbonate 24 hr after overdose or
plasma creatinine normal at 24 hr
when antidote treatment complete
after overdose, or after antidote
l if INR >1.3 or creatinine raised, or
treatment complete, with warning to
patient acidotic, continue treatment
return if vomiting or abdominal pain
(IV acetylcysteine 150 mg/kg over
occur
24 hr)
l recheck INR and U&E 12 hrly until
clearly falling
l If INR 1.3, AST/ALT and plasma
l INR, AST/ALT, creatinine,
creatinine normal:
bicarbonate and phosphate 24 hr
l discharge asymptomatic patients
after overdose or when antidote
12 hr after antidote treatment with
treatment complete
warning to return if vomiting or
l if INR >1.3 or creatinine raised, or
abdominal pain occur
patient acidotic, continue treatment
l if INR >1.3 and rises, and/or plasma
(IV acetylcysteine 150 mg/kg over
creatinine raised after antidote
24 hr)
treatment, monitor and observe until
l recheck INR and U&E 12 hrly until
these indices are falling and INR <2.0
clearly falling
l discuss with NPIS
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Life-threatening features
Psychiatric review
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83
Plasma
paracetamol
(mg/L)
84
Plasma
paracetamol
(mmol/L)
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Expires: November 2012
Common preparations
l Chlorpromazine
l Perphenazine
l Prochlorperazine
l Promazine
l Trifluoperazine
l Metoclopramide
Treatment of extrapyramidal
side effects
l Procyclidine orally
l in severe reactions give IV or IM
l subsequent oral doses may be
needed for 23 days
l if procyclidine not available, give
benztropine or diazepam
MONITORING
TREATMENT/SUBSEQUENT
MANAGEMENT
Complications
l Convulsions
l Hypothermia
l Hypotension
l Arrhythmias (e.g. sinus tachycardia,
QT and QRS prolongation, VT/VF,
bundle branch/atrio-ventricular block)
l Respiratory depression
l Rhabdomyolysis
l Renal failure
IMMEDIATE TREATMENT
85
Uncommon features
l Haematemesis
l Hyperpyrexia
l Hypoglycaemia
l Hypokalaemia
l Thrombocytopenia
l Increased INR/PTR
l Intravascular coagulation
l Renal failure
l Non-cardiac pulmonary oedema
l Confusion
l Disorientation
l Coma
l Convulsions
Preparations
l Aspirin tablets
l Methylsalicylate (Oil of Wintergreen),
very toxic
l Choline salicylate (dental gels)
l Numerous over-the-counter
analgesics/antipyretics contain aspirin
86
Investigations
l U&E, creatinine
l INR
l Arterial blood gases
l Blood glucose (capillary)
l In asymptomatic patients with a
reliable history of ingestion of
<120 mg/kg of aspirin, plasma
salicylate not required
l In those who have ingested
>120 mg/kg, measure plasma
salicylate at least 2 hr (if
symptomatic) or 4 hr (if
asymptomatic) after ingestion
l If coincident paracetamol overdose
requiring infusion of antidote, sample
before administration of Nacetylcysteine
l Urine pH
Assessment of severity
l Severity cannot be assessed from
plasma salicylate concentrations alone
l Neurological features (e.g. confusion
and impaired consciousness),
metabolic acidosis, and high
salicylate concentrations indicate
severe poisoning
l Risk factors for death include:
l aged <10 yr
l CNS features
l acidosis
l hyperpyrexia
l late presentation
l pulmonary oedema
l salicylate concentration >5.1 mmol/L
IMMEDIATE TREATMENT
l If ingested >125 mg/kg salicylate
within previous hr, give oral activated
charcoal 1 g/kg (maximum 50 g),
mixed with soft drink/fruit juice if
necessary to disguise taste
l Consider gastric lavage if taken
>500 mg/kg within 1 hr
l Rehydrate orally (IV if vomiting)
Issue 4
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Expires: November 2012
MONITORING
TREATMENT/SUBSEQUENT
MANAGEMENT
l See Poisoning and drug overdose
guideline
l During alkaline diuresis, check U&E,
blood glucose, acid-base hourly
l Repeat plasma salicylate 2 hrly until
falling
l if plasma salicylate continues to rise,
consider a second dose of activated
charcoal
l Continue therapy until patient
improving and plasma salicylate
falling
l Follow guidance on www.toxbase.org
(password from A&E)
l Further advice from National Poisons
Information Service (0844 892 0111)
87
l Metabolic acidosis
l Hypokalaemia
Severe cases
l Hypotension
IMMEDIATE TREATMENT
If a benzodiazepine has also
been taken, do NOT give
flumazenil
l Correct any hypoxia
l Seizures
l Respiratory depression
l Cardiac arrhythmias
Preparations
l Amitriptyline
l Amoxapine
l Clomipramine
l Dosulepin
l Doxepin
l Imipramine
l Lofepramine
l Nortriptyline
l Trimipramine
Investigations
l U&E
88
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89
PRINCIPLES
Reasons to control diabetes well in perioperative period
l To prevent hyperglycaemia and ketoacidosis, resulting from:
l omission of insulin
l stress hormone response to surgery
l catabolic state
l To minimise risk of infection,
enhanced by hyperglycaemia
l To prevent hypoglycaemia, resulting
from:
l starvation pre- and post-operatively
l anorexia post-operatively
90
Post-operative care
EMERGENCY SURGERY
Pre-operative care
Pre-operative care
l Inform diabetes team immediately
l Do not give any SC insulin while child
starved
l Check venous U&E, glucose, blood
gas when child cannulated
l Commence glucose and sliding scale
insulin infusion see below
l Measure and record capillary blood
glucose hourly once nil-by-mouth and
half-hrly during operation
Insulin infusion
l Add 50 units soluble insulin (e.g.
Actrapid) to 50 mL of sodium chloride
0.9% to make a 1 unit/mL solution
l Administer via syringe pump, do not
add directly to fluid bag
91
Post-operative care
l Check capillary blood glucose halfhrly for the first 2 hr and then hourly
l Continue glucose and sliding scale
insulin infusion until taking adequate
oral fluids and snacks. While on
insulin sliding scale, child may safely
eat and drink
Table 1
Capillary blood glucose (mmol/L)
28.1
18.128
12.118
8.112
4.18
4
92
Resuscitation 2
l Airway + NG tube
l Breathing (100% O2)
l Circulation (sodium
chloride 0.9% 10
mL/kg repeated until
circulation restored,
max 3 doses)
No improvement
Re-evaluate
l Fluid balance + IV
therapy
l If continued acidosis,
may require further
resuscitation fluid
l Check insulin dose
correct
l Consider sepsis
Dehydration <5%
Clinically well
Tolerating fluid orally
pH >7.3
Diabetic ketoacidosis
Call senior staff
Immediate treatment 1
Shock
See 2 for definition
Dehydration >5%
Vomiting or
Biochemically acidotic
Therapy
l Start with SC insulin
l Give oral fluids
Intravenous therapy 3
l Calculate fluid requirements
l Correct over 48 hr, never less
than 12 hr
l Sodium chloride 0.9%
l Use premixed bags with KCl
l Insulin 0.050.1 units/kg/hr by
infusion (after first hour of fluids).
Starting dose 4 (alter as per local
policy)
l
l
l
l
No improvement
Blood ketones rising
Looks unwell
Starts vomiting
Neurological
deterioration
l Warning signs:
l headache, irritability,
slowing heart rate,
reduced conscious
level
l Specific signs
l raised intra-cranial
pressure
Monitoring 5
Blood glucose half-hrly, then
hourly
Neurological status at least
hourly
Fluid input/output hourly
Electrolytes 2 hr after start of IV
therapy, then 4 hrly
Exclude hypoglycaemia
? cerebral oedema
Subsequent management 6
l Change to sodium chloride 0.9%/0.45% + glucose 5%
l Use premixed bags containing KCl
l Continue monitoring as above
Insulin 7 8
Start SC insulin then
stop IV insulin
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Expires: November 2012
Improvement 8
l Clinically well, drinking
well, tolerating food
l Blood ketones <1.0 mmol/L
or pH normal
l Urine ketones may still be
positive
l
l
l
l
Management
Give sodium chloride
2.7% 5 mL/kg or
0.51g/kg mannitol
Call senior staff
Restrict IV fluids by half
Move to PICU
CT scan when stabilised
93
Thirst
Weight loss
Polyuria
Abdominal pain/vomiting
Tachypnoea
Sighing respiration (Kussmaul breathing)
Odour of ketones
Dehydration
Drowsiness
Coma
Biochemical signs:
ketones in urine or blood
elevated blood glucose (>11 mmol/L)
acidaemia (pH <7.3)
Assessment
l Airway, breathing, circulation
l record respiratory rate, heart rate, BP,
peripheral pulse volume
l Conscious level: look for signs of
cerebral oedema (see Glasgow
coma score)
l Headache, confusion, irritability,
abnormal movements, slow pulse,
high BP, papilloedema, small and
irregular pupils
l Presence of infection
l Height, weight
Degree of dehydration
l Assessment degree of dehydration as
3%, 5% and 8% (for most children use
58% dehydration to calculate fluids)
Investigations
l Insert IV cannula (as large as
appropriate for child)
All cases
l Capillary blood glucose
l FBC
94
l Blood glucose
l Blood gas
l Haemoglobin A1c
l Blood osmolality, sodium, potassium,
urea, bicarbonate, creatinine, pH
l Urine ketones on urinalysis
l Blood ketones
l Infection screen: blood and urine
culture; if meningism consider lumbar
puncture
IMMEDIATE TREATMENT
General
l Nil-by-mouth for first 812 hr
l if vomiting, complaining of abdominal
pain or has silent abdomen, insert
nasogastric tube
l Place on weigh-bed (if available)
l Strict fluid balance: catheterise
children requiring HDU or PICU
l Start flow-sheet to record
biochemistry and blood gases
l Monitor ECG for T wave changes
l Initiate IV fluids and insulin (see
below)
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INTRAVENOUS FLUIDS
Volume of fluid
Weight (kg)
Maintenance fluids
l Patient will be nil by mouth and will
need normal fluid requirement IV
012.9
80
160
1319.9
65
130
2034.9
55
110
3559.9
45
90
>60
35
70
Fluid deficit
l Estimated amount of fluid patient has
lost, (i.e. how dehydrated see
Assessment)
l Calculate from weight loss
l Most accurate method
l weigh child and compare with recent
weight
l gives good estimate of fluid loss (1 kg
weight loss = 1 L fluid deficit)
l Clinical assessment
l deficit in mL = % dehydration x body
weight (kg) x 10 (e.g. for a 10 kg child
with 5% dehydration, the deficit is
5x10x10 = 500 mL)
l do not use more than 8% dehydration
in calculations
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Total Amount
l Hourly rate of fluid replacement =
(48 hr maintenance requirements +
deficit resuscitation fluid already
given)/48
l Weight should rise gradually with
rehydration
l If available use weigh-bed to record
weight hourly to obtain accurate
assessment
Type of fluid
l Initially use sodium chloride 0.9% with
potassium chloride, and continue this
concentration for at least 12 hr
95
K+ <3.5
500 mL sodium
chloride 0.9% with
potassium chloride
40 mmol
(commercially
premixed bag)
If serum potassium
<2.5 mmol/L, transfer to PICU.
Discuss with consultant
whether to give potassium
chloride 0.2 mmol/kg in sodium
chloride 0.9% by separate
infusion over 1 hr. Before
infusing bag containing
potassium, connect patient to
cardiac monitor.
If possible, use commercially
premixed bag to approximate
calculated strength of
potassium chloride. Only in
exceptional circumstances
(with consultant agreement and
2 doctors checking procedure)
should potassium chloride be
added on the ward to a bag of
sodium chloride 0.9% (mix well)
l Further fluid and K+ as dictated by the
patients condition and serum K+
(Table 1), repeated until glucose
fallen to 14 mmol/L, then move to
Subsequent management
96
K+ 3.55.5
1 L sodium chloride
0.9% with potassium
chloride 40 mmol/L
(commercially
premixed bag)
K+ >5.5
1 L sodium chloride
0.9%
SUBSEQUENT MANAGEMENT 6
After a minimum 12 hr of initial
intravenous therapy, if plasma
sodium level stable or
increasing, change sodium
concentration to sodium
chloride 0.45%
When blood glucose falls below
14 mmol/L add glucose to fluid
l Once blood glucose has fallen below
14 mmol/L, use fluid regimen in Table 2
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K+ 5.5
500 mL glucose 5% with
sodium chloride 0.45% and
potassium chloride 20 mmol
(commercially premixed bag)
Time (hr)
Use hourly rate
If serum potassium is
<2.5 mmol/L, discuss with
consultant. Follow instructions
under Table 1
l Keep insulin infusion rate at or reduce
to 0.05 units/kg/hr
l Blood glucose may rise as a result,
but do not revert to sodium chloride
0.9% unless plasma pH falls
K+ >5.5
1 L glucose 5% with sodium
chloride 0.45%
Table 3
Time (hr)
Use hourly rate
K+ <3.5
If serum potassium is
<3.5 mmol/L, discuss
fluid management with
consultant
K+ 3.55.5
500 mL glucose 10%
with sodium chloride
0.45% and potassium
chloride 10 mmol
K+ >5.5
1 L glucose 10% with
sodium chloride
0.45%
Cerebral oedema
l Inadequate resuscitation
l Hyperchloraemic acidosis
l Sepsis
l admit to PICU
97
98
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l Weight loss
l Thrush
l Polyuria
l Nocturia
l May be absent
Investigations
l Height and weight
l haemoglobin A1C
l FBC
l immunoglobins A, G and M
l ketones
l glucose
l Blood:
l electrolytes
l glucose
l pH
l ketones
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99
MONITORING TREATMENT
l Glucose stick monitoring pre-meals
and at 0000 and 0400 hr
100
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HYPOGLYCAEMIA 1/6
Unexplained and prolonged
RECOGNITION AND
ASSESSMENT
Definition
l Neuroglycopenia:
l lethargy
l lassitude
l tremulousness
l loss of consciousness
l seizure
l Autonomic effects:
l sweating
l shaking
l trembling
l tachycardia
l anxiety
l hunger
Previous history
l Ask about:
l antenatal history (e.g. small-for-dates)
l prematurity
l history of hypoglycaemia on the
neonatal unit
l early or prolonged jaundice
l family history of sudden death
(MCAD, LCAD)
l history of neuroglycopenia/autonomic
symptoms when glucose intake
decreased, (e.g. during minor
illnesses)
l development, especially
developmental regression
l medication
l access to glycopenic agents (e.g.
metformin)
l oral hypoglycaemics
l nutritional intake
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Investigations
Certain pointers to cause of
unexplained hypoglycaemia are
detectable only during episode.
Take blood samples BEFORE
correcting blood glucose
Immediate samples
l Before treating hypoglycaemia, take
venous blood for assay using correct
blood bottles (Table 1)
l once samples have been obtained,
correct hypoglycaemia. See
Immediate treatment
1.3 mL
Lithium heparin
Clotted
1.3 mL
2.6 mL
101
HYPOGLYCAEMIA 2/6
Investigations1
Physcial examination
l Height and weight
l Midline defects, micropenis, optic
nerve hypoplasia (pituitary disorder)
l Dysmorphic features: macroglossia,
macrosomia, ear lobe crease
(Beckwith-Wiedemann)
l Skin hyperpigmentation (adrenal
insufficiency)
l Hepatomegaly (glycogen storage
disorder)
UHNS: use laboratory request forms with hypoglycaemia sticker and complete
clinical details requested
102
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HYPOGLYCAEMIA 3/6
Differential diagnosis
First-line investigations
before correcting glucose:
lInsulin
lGrowth hormone
lC-peptide
lCortisol
lUrinary ketones
lACTH
Ketones absent
Ketones present
See algorithm on
next page
Present
Absent
Hereditary
fructose
intolerance or
galactosaemia
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Serum insulin
>510 micro
units/mL
Fasting
glucagon test
(refer to
specialist
centre)
C-peptide
Hyperinsulinaemia
High
Insulinoma
Low
Exogenous
insulin
Fatty acid
oxidation or
carnitine defect
103
HYPOGLYCAEMIA 4/6
Differential diagnosis
Ketones present
Growth
hormone and
cortisol normal
Hepatomegaly
ACTH level
Yes
Glycogen
storage
disease
104
No
Ketotic
hypoglycaemia
Low
High
Hypopituitarism
Adrenal
insufficiency
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HYPOGLYCAEMIA 5/6
IMMEDIATE TREATMENT
Glucose sticks
<2.6 mmol/L
GCS 8
and well
GCS <8
(seek help)
IV access
l Take blood for hypoglycaemia
investigation and obtain urine sample for
ketones
l If available check blood for ketones
2.6 mmol/L
<2.6 mmol/L
Recheck glucose
sticks after 10 min
<2.6 mmol/L
2.6 mmol/L
Continue
glucose
infusion
Reassess
ABCD and
discuss further
management
with consultant
l Failure of blood glucose to respond to extra glucose suggests possible underlying metabolic
problem related to either:
l excessive insulin production or exogenous insulin
l inability to utilise glucose owing to hypopituitarism or adrenal insufficiency
l In either case further therapeutic manoeuvres need to be used see Subsequent
management
* Add 7.5 mL sodium chloride 30% to 500 mL glucose 10%
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105
HYPOGLYCAEMIA 6/6
SUBSEQUENT MANAGEMENT
<2.6 mmol/L
>2.6 mmol/L
l
l
l
l
l
l
l
l
l
106
Endocrine opinion
Consider:
octreotide
diazoxide
glucagon
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0.11.0
mmol/L
1.13.0
mmol/L
Acceptable levels
>3.0
mmol/L
Need to reduce
blood ketones to
1 mmol/L
Treat high
blood glucose
Contact on-call
paediatric SpR to
childrens
diabetes team
If unwell refer to
sick day dose
flowchart
YES
Start DKA
protocol
Give additional rapid acting insulin by SC injection
and refer to sick day dose flowchart
Dose calculation: either
(a) 10% of total daily dose to maximum of 10 units/dose
OR
(b) 0.1 unit of insulin/kg body weight
If pump user, administer by insulin pen or syringe, then replace infusion set and check
insulin pump
Blood ketones
falling
Recheck blood
ketones in 1 hr
1.0
>1.0
mmol/L mmol/L
Blood ketones
falling
Recheck blood
ketones in 1 hr
Contact
on-call
paediatric
SpR or
childrens
diabetes
team
Blood
ketones not
falling
If unsure, especially if child aged <5 yr, contact childrens diabetes team
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107
RECOGNITION AND
ASSESSMENT
Definition
l Children with the following conditions
are corticosteroid-dependent with a
depressed or absent pituitary-adrenal
axis:
l hypopituitarism
l adrenal insufficiency
MANAGEMENT
Elective surgical and
investigative procedures
l growth hormone
l levothyroxine
l desmopressin
Acute illness
l During illness, corticosteroiddependent children can usually be
managed at home
108
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IV access
If glucose stick
<2.6 give bolus of
glucose 10%
5 mL/kg
l
l
l
l
l
l
Correct electrolyte
abnormalities (see
Diarrhoea and
vomiting guideline)
Hydrocortisone
4 mg/kg IV bolus
Commence
hydrocortisone
24 mg/kg 6 hrly
IV
l Regularly monitor BP
and blood glucose
l Titrate infusion
accordingly, i.e. low
BP and/or glucose
stick then increase
infusion rate
l Once able to tolerate oral fluids, convert to oral corticosteroids (at double the patients normal
daily dose)
l consider treble usual corticosteroid dose initially
l for simplicity, double patients highest dose of the day (as may be different doses throughout
day)
l Continue double/triple normal daily dose of corticosteroid until two to three days after
recovery from acute episode
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109
Mid-gut volvulus
l Presents mainly in neonatal period
l History of:
l bowel obstruction
l abdominal pain
l distension
l Anorexia
l bilious vomiting
l Fever
l On examination
Differential diagnosis
Surgical problems
Intussusception
l Typical age of presentation:
2 months2 yr
110
l Acute appendicitis
l Intussusception
l Intestinal obstruction
l Enterocolitis secondary to
Hirschprungs disease
l Gastroenteritis
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l Acute cholecystitis
l Primary peritonitis
l Non-accidental injury
INVESTIGATIONS
l
l
l
l
Imaging
l Only if bowel obstruction or
perforation suspected: abdominal
X-ray
l If child stable and suspect
appendicitis, intussusception, torsion
of ovary or testis, renal problems,
pancreatitis or cholecystitis:
ultrasound scan of abdomen
l If respiratory symptoms: chest X-ray
l Do not delay surgical review awaiting
scans if acute surgical problem
suspected (e.g. torsion of the testis)
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MANAGEMENT
Observation
l If stable, period of observation may
be useful to make diagnosis
Analgesia
l Do not withhold analgesia pending
surgical review: opioids may be
necessary (see Analgesia guideline)
111
CONSTIPATION 1/4
RECOGNITION AND
ASSESSMENT
Definition
l Constipation: infrequent bowel
evacuation of hard faeces or
difficult/painful defaecation for 1 month
l Faecal soiling: (overflow as a result
of faecal impaction): passage of liquid
or formed stools in childs underwear
over which child has no control
l Encopresis: (functional non-retentive
soiling): inappropriate passage of
normal stools in inappropriate places.
Often associated with behavioural
problems
l Faecal incontinence: soiling in the
presence of an anatomical or organic
lesion
l Faecal impaction: hard faecal mass
in lower abdomen, a dilated rectum
impacted with stool or excessive stool
in the colon identified radiologically
DIFFERENTIAL DIAGNOSIS
l Idiopathic functional constipation
(9095%). Most common cause of
constipation beyond neonatal period
CONSTIPATION 2/4
l Constipation induced by drugs (opioids)
l Coeliac disease
INVESTIGATIONS
l Most children with chronic
constipation require minimal
investigation:
l careful history and physical
examination will help determine
appropriate investigation
Abdominal X-ray
l Has little or no value in the diagnosis
of idiopathic constipation
l lower spine X-ray may be useful in an
encopretic child with no faecal
masses on abdominal and rectal
examination
MANAGEMENT OF
FUNCTIONAL CONSTIPATION
Principles of treatment
l
l
l
l
l
Education
Diet and lifestyle
Behavioural management
Medication
Supporting child and family
Education
l Give parents clear explanation of
pathophysiology of constipation and
soiling
Issue 4
Issued: November 2010
Expires: November 2012
Behavioural management
l Use of behavioural management in
combination with medications
decreases time to remission
Medication
l In the presence of impacted stools
Disimpaction
Aged <1 yr, refer to paediatric
gastroenterologist
1. A macrogol laxative [polyethylene
glycol (e.g. Movicol paediatric plain)];
faecal impaction dose, see below up
to a maximum of 7 days
2. Use stimulant laxative, senna or
sodium picosulphate (Picolax) if no
result with macrogol or if not
tolerated
113
CONSTIPATION 3/4
Disimpaction dosage (number of Movicol paediatric plain sachets daily divided into
2 doses 12 hrly)
AGE (yr)
15
512
Day 1
2
4
Day 2
4
6
Day 3
4
8
Rectal disimpaction
(only if oral disimpaction fails)
Manual evacuation
l If all above have failed, consider
manual evacuation under general
anaesthetic. Consult with paediatric
gastroenterologist or paediatric surgeon
MAINTENANCE THERAPY
l After disimpaction, or if child had no
impaction, focus treatment on
prevention of recurrence and
establishment of a regular bowel habit
to allow bowel to regain normal tone
and sensation
l Continue maintenance therapy for 46
months then reduce dosage gradually
l half the dismpaction dose of Movicol
is a useful guide for initial
maintenance dose
Laxatives
Day 4
6
10
Day 5
6
12
Day 6
8
12
Day 7
8
12
Withdrawal of laxatives
l Once regular bowel habit has been
established for a few months, and
child has good sensation to pass
stools, gradually withdraw laxatives
Issue 4
Issued: November 2010
Expires: November 2012
CONSTIPATION 4/4
CONSTIPATION MANAGEMENT
l History
l Physical
examination
Yes
Evaluate
further
No
FUNCTIONAL CONSTIPATION
Is there faecal impaction?
No
Yes
l Disimpact orally
l Only use rectal preparations if oral
medication fails. Ensure child consents
and is not distressed
l
l
l
l
l
l
Treatment:
education
diet and lifestyle
oral medication
behavioural therapy
close follow-up
Effective?
No
Treatment effective?
Is there faecal impaction?
No
Yes
Yes
No
l
l
l
l
Re-assessment
Compliance
Re-education
Change medication
Yes
Relapse?
Treatment effective?
Yes
No
No
l
l
l
l
l Wean
l Observe
Blood tests:
T4 and TSH
Coeliac antibodies
calcium and lead
Yes
Evaluate further
No
115
l weight loss
l Loss of appetite
Patient history
l Ask about:
l duration of illness
116
Issue 4
Issued: November 2010
Expires: November 2012
Symptoms (remote
and face-to-face
assessment)
No clinically
detectable
dehydration (<5%)
Clinical shock
>10% dehydration
Appears well
Appears to be unwell
or deteriorating
Altered responsiveness
(e.g. irritable, lethargic)
Decreased level of
consciousness
Warm extremities
Warm extremities
Cold extremities
Signs
(face-to-face assessment)
Clinical dehydration
510% dehydrated
Altered responsiveness
(for example, irritable,
lethargic)
Decreased level of
consciousness
Warm extremities
Warm extremities
Cold extremities
Sunken eyes
Tachycardia
Tachycardia
Tachypnoea
Tachypnoea
Issue 4
Issued: November 2010
Expires: November 2012
Hypotension
(decompensated shock)
117
IMMEDIATE TREATMENT
See flowchart Management of acute
gastroenteritis in young children
Continue breastfeeding
throughout episode of illness,
ORS can be given in addition
118
Treatment of dehydration
l Admit if:
l patient 10% dehydrated
l failure of treatment (e.g. worsening
diarrhoea and/or dehydration)
l other concerns (e.g. diagnosis
uncertain, child aged <3 months,
irritable, drowsy, potential for surgery)
In hypernatraemic dehydration,
aim to reduce sodium by no
more than 10 mmol in 24 hr
l After initial resuscitation, give ORS:
replace deficit (+ maintenance) over
48 hr via NG if necessary
l Check U&E after 1 hr
Hypernatraemic dehydration
(Na >150 mmol/L)
l In hypernatraemic dehydration, there
are fewer signs of dehydration
Issue 4
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Expires: November 2012
119
Shock
Reassess
No
Oral/NG tube
rehydration possible
No
Yes
Rehydrate orally or
via NG tube
Measure
serum sodium
Low/normal
(<150 mmol)
Maintenance and
replacement over 24 hr
120
Clinician estimates %
dehydration and
current weight
One or more of
following present?
l >10% dehydration
l Signs of shock
l Patient drowsy
Yes
l Hospitalise
l Give sodium chloride 0.9% IV bolus if
shock
l Re-evaluate and repeat if necessary
see Management of acute dehydration
l Begin ORS, replacing deficit (up to
100 mL/kg) over 4 hr plus replacement of
ongoing losses (oral/NG)
No
Is patient 69%
dehydrated by weight
loss or by clinical
estimation?
Yes
No
Is patient 35%
dehydrated by weight
loss or by clinical
estimation?
Yes
No
Patient with diarrhoea
and <3% dehydration on
clinical
estimation/current weight
Yes
l Continue childs regular diet
l Consider adding ORS to
replace ongoing losses
Issue 4
Issued: November 2010
Expires: November 2012
Patient
tolerating
ORS
No
l Continue breastfeeding
l Resume foods
l NG rehydration
l Institute IV infusion l Replace ongoing
losses with ORS
121
YES
TPN
Pharmacy
manufacturing
Mon-Fri
If not available,
use sodium
chloride 0.45% +
glucose 5%
with 10 mmol
potassium
chloride in
500 mL (use
commercial premixed bags)
monitor U&E
Breast milk
Nutramigen
If MCT * needed
use Peptijunior/
Pregestimil
feeds above are
peptide based
If not tolerated,
try Neocate
L-amino acid
Aged
<1 yr
Malabsorption
Normal gut
Pre-digested/
hydrolysed
protein feed
Whole protein
feed
Aged 1 yr
Wt 820 kg
Peptamen
junior
Pepdite 1+
Paediasure
Pepdite
OR use <1 yr
feeds until
dietitian
review
Aged >6 yr
Wt >20 kg
Peptisorb,
Peptamen
peptide
based
Elemental
028 Extra-L
amino
acids
Aged
<1 yr
Breast
milk**/std
infant
formula
If failure to
thrive or fluid
restriction,
use Infatrini/
Similac
High Energy
SMA
High Energy
Aged 1 yr
Wt 820 kg
Nutrini
Paediasure
Frebini
original
Aged >6 yr
Wt >20 kg
Tentrini up
to 45 kg
Paediasure
up to 30 kg
Frebini
original up
to 30 kg
Nutrison
Standard
Fresubin
original
Osmolite
l Contact dietitian to assess individual requirements and appropriate feed at the first available
opportunity MondayFriday
l Feeds in bold must be prescribed
l Hospital pharmacy will advise which feed is used locally (all similar composition for ages but
different manufacturer)
l See Table 1 for daily fluid and nutritional requirements
*Indications for MCT: malabsorption, or problems with digestion, absorption or transport of long
chain fats e.g. cholestasis, short gut, pancreatic insufficiency
** Dietitian to advise on fortification of breast milk if fluid restricted or failure to thrive
l Nutriprem breast milk fortifier 1 sachet (2.1 g) per 50 mL expressed breast milk (EBM) can be
added until dietitian advice given
122
Issue 4
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Expires: November 2012
Average
weight
(kg)
03 months
6
46 months
7.5
79 months
9
1012
10
months
13 yr
female
12
male
12.5
4 yr
female
16
male
16.5
5 yr
female
18
male
18.5
6 yr
female
20.5
male
21
710 yr
female
27
male
27
1114 yr
female
43
male
40
1518 yr
female
56
male
62.5
Fluid
Energy
mL/kg per *EAR/day
day
150
130
120
110
Energy
Kcal/kg
per day
100115
95
95
95
Protein
g/kg per
day
2.1
1.6
1.5
1.5
95
1165
1230
95
95
1460
1520
87
94
1550
1720
82
88
1620
1810
76
84
1740
1970
70
70
1845
2220
47
55
2110
2755
40
45
95
95
85
75
55
Sodium Potassium
mmol/kg mmol/kg
per day
per day
1.5
3.4
1.6
2.8
1.6
2.0
1.5
1.8
1.1
1.7
1.6
1.1
1.9
1.6
1.1
1.9
1.6
1.1
1.9
1.6
1.0
1.8
1.8
1.0
1.6
1.8
1.3
1.0
1.6
1.4
1.0
50
Kcal
Protein
g
Fat
g
CHO
g
Na
mmol
K
mmol
Osmolality
70
67
100
101
91
68
67
71
100
100
100
100
100
100
100
100
100
1.3
1.4
2.6
2.6
2.0
1.9
1.8
2.0
2.8
2.8
4.0
4.0
3.0
3.0
3.1
4.0
4.0
4.2
3.5
5.4
5.4
4.9
3.4
3.6/50% MCT
3.5
4.5
5.0
3.9
3.4
4.0/50% MCT
3.9/60% MCT
3.9/35% MCT
1.7/47% MCT
3.7/70% MCT
7.2
7.5
10.4
10.3
9.8
7.4
6.9
6.6
12.2
11.2
12.3
13.6
13.0
13.8
13.0
17.6
12.7
0.6
0.8
1.0
1.1
1.0
1.4
1.4
0.9
2.3
2.6
3.5
3.83
3.0
2.9
2.1
4.3
2.6
1.5
1.7
2.6
2.3
2.3
1.9
1.9
1.6
2.6
2.8
3.5
3.8
3.9
3.5
3.0
3.8
2.8
276
330
310
333
415
290
190
360
250
320
310
288
320
260
465
520
240
85
2.5
3.5/35% MCT
11
2.7
2.4
700
1.5
123
124
Issue 4
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Expires: November 2012
Measurements
Measurements must be carried out
properly and checked if there is doubt
l Record birth weight and gestation
l some light-for-dates infants fail to
catch up, and grow parallel but below
the 3rd percentile
l Measure and plot
l weight (unclothed)
l head circumference
l length or height
l Infant may be a small, normal child
growing below but parallel to the 3rd
percentile
l parents are often also small
l record height of parents and
grandparents
Issue 4
Issued: November 2010
Expires: November 2012
Investigations
Routine tests
l Faeces: culture and sensitivity,
microscopy for ova and cysts and
parasites
l Urine: dipstick for protein, nitrites and
blood
l Haemoglobin, blood film (for signs of
iron deficiency), WBC and ESR
l Biochemical profile including creatinine,
bicarbonate, calcium and albumin
l Coeliac screen (anti-tTG and IgA)
125
MANAGEMENT
l Chest X-ray
l Bone age
l If underlying pathology indicated by
history or clinical examination or
results of routine investigations,
request further tests, such as:
l sweat test/cystic fibrosis (CF) gene
l Further gastrointestinal investigation or
management of malabsorption
disorders should be undertaken by
referral to specialist gastroenterology
team who will undertake as
appropriate:
l endoscopy or jejunal biopsy
l gastrointestinal imaging
Differential diagnosis
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
l
126
Issue 4
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Expires: November 2012
JAUNDICE 1/3
RECOGNITION AND
ASSESSMENT
Investigations
All
Assess
l Pallor (haemolysis)
Causes
l Physiological
l Prematurity
Persistent jaundice
l congenital spherocytosis
l Urine M,C&S
l TPN-induced cholestasis
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Expires: November 2012
127
JAUNDICE 2/3
l Congenital infection screen:
l blood galactose-1-phosphate
Limits (micromol/L) for phototherapy and exchange transfusion for term infants
Age
(hours)
Repeat transcutaneous
bilirubin/serum bilirubin
(612 hours)*
Consider
phototherapy #
Phototherapy
Exchange
transfusion
>100
>112
>100
>100
>125
12
>100
>150
>125
>150
18
>200
>100
>137
>175
>250
24
>100
>150
>200
>300
30
>112
>162
>212
>350
36
>125
>175
>225
>400
42
>137
>187
>237
>450
48
>150
>200
>250
>450
54
>162
>212
>262
>450
60
>175
>225
>275
>450
66
>187
>237
>287
>450
72
>200
>250
>300
>450
78
>212
>262
>312
>450
84
>225
>275
>325
>450
90
>237
>287
>337
>450
96+
>250
>300
>350
>450
128
Issue 4
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Expires: November 2012
JAUNDICE 3/3
TREATMENT <7 DAYS
l Adequate fluid and energy intake
l Phototherapy
After first 24 hr
l Commence phototherapy according to
following equation:
l for infants <37 weeks, start if serum
bilirubin (micromol/L) phototherapy
level [(gestational age in completed
weeks x 10) 100]
l for infants 37 weeks, start if serum
bilirubin >340 micromol/L
(phototherapy level)
Phototherapy
l If bilirubin near exchange threshold or
still rising:
MONITORING TREATMENT
l If haemolysis present, check bilirubin
46 hrly until rate of rise flattens
SUBSEQUENT MANAGEMENT
l When bilirubin concentration has fallen
below threshold for phototherapy (see
above), discontinue phototherapy
l If jaundice persists after 14 days of
age, review and treat cause
Exchange transfusion
l See Exchange transfusion in
Neonatal guidelines
IVIG
l Use as an adjunct to multiple
phototherapy in rhesus disease when
bilirubin continues to rise by
>8.5 micromol/L/hr
Issue 4
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Expires: November 2012
129
BLOOD TRANSFUSION
When to transfuse
Oncology children
Non-oncology children
Rate of infusion
l Give total over 34 hr. Max rate
5 mL/kg/hr
130
Leucodepleted blood
l All packed cells are leucodepleted
and therefore CMV negative
PLATELET TRANSFUSION IN
ONCOLOGY CHILDREN
Transfuse platelets if
platelet level
Idiopathic thrombocytopenic
purpura (ITP) transfuse
platelets only if bleeding
Issue 4
Issued: November 2010
Expires: November 2012
IMMEDIATE TREATMENT
See Table 1 and Figure 1
All patients
l Culture both lumens/portacath, FBC,
CRP, urine dipstick. CXR if respiratory
signs
l Follow local microbiology advice: if
local microbial resistance to 1st line
antibiotics start with 2nd line
l Repeat blood culture before any
change in antibiotics
l stop antibiotics
131
Gentamicin
Teicoplanin
l
l
l
l
l
l
l
l
l
l
l
Meropenem
Vancomycin
Antifungal therapy
Liposomal
amphotericin
(AmBisome)
l
l
90 mg/kg 6 hrly
Reduce frequency in renal impairment
Maximum single dose 4.5 g
If rash with penicillin use ceftazidime
If anaphylaxis with penicillin use aztreonam
7 mg/kg once daily based on IBW
Pre-dose level before third dose or, if creatinine clearance <70 mL/min,
before second dose
No post-dose level required
Target pre-dose level <1 mg/L
Staphylococcal CVL infections well enough to be treated as an outpatient if sensitive (if MIC >8 mg/mL use vancomycin)
10 mg/kg (max 400 mg/dose) 12 hrly for three doses followed by
10 mg/kg/day (max dose 400 mg/day)
20 mg/kg 8 hrly
Maximum of 3 g/day
l 15 mg/kg 8 hrly
l Dose should be given over at least 60 min at maximum rate of
10 mg/min
l Maximum of 2.1 g/day until concentration known
l Pre-dose sample before third dose
l No post-dose sample required
l Adjust dose as follows:
l pre-dose concentration (mg/L)
l <10 give 6 hrly and recheck concentration in 2448 hr
l 1015 continue current dose and recheck concentration in 35 days
l 1520 reduce frequency of dosing and recheck concentration in 2448 hr
l >20 stop vancomycin and recheck concentration next day to see if
therapy can be restarted
l Give test dose 100 microgram/kg
l 1 mg/kg/day
l If strong clinical/microbiological evidence of fungal infection, increase
to 3 mg/kg/day
132
Issue 4
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Expires: November 2012
FIRST
LINE
Unwell or
febrile at
48 hr
SECOND
LINE
Clinically stable
and apyrexial at
48 hr
Continue first line
antibiotics
Chase
blood
cultures
Antifungal therapy
* If patient penicillin allergic, start ceftazidime 50 mg/kg 8 hrly (max dose 2 g) and gentamicin
7 mg/kg once daily
If receiving nephrotoxic drugs or has renal impairment, substitute teicoplanin for vancomycin
Issue 4
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Expires: November 2012
133
Gastrointestinal tract
l Abdominal pain mostly idiopathic,
typically resolves in 72 hr
l Intestinal haemorrhage:
haematemesis, melaena, bloody stools
(rare)
Joints
l Arthralgia and swelling of large joints,
especially ankles and knees. Pain
typically resolves in 2448 hr
l Oedema of hands, feet, sacrum and
scrotum
Renal
l Microscopic haematuria (common)
Neurological
l Headache (common)
Differential diagnosis
l Purpuric rash:
Investigations
All patients
l BP
l Urine dipstick
Additional investigations
Blood tests if urinalysis abnormal or
diagnosis uncertain
l FBC+ film
l U&E
l Albumin
l Throat swab
134
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Expires: November 2012
Joint pain
l NSAIDs (ibuprofen first-line,
indometacin or diclofenac second-line)
Abdominal pain
l Give prednisolone as for nephrotic
syndrome. Renal involvement not a
contraindication
l If severe and persists, exclude
pancreatitis, intussusception. or
spontaneous bowel perforation
MONITORING
Uncomplicated HSP (e.g. urine
analysis 1+ blood and protein,
and normal BP)
Issue 4
Issued: November 2010
Expires: November 2012
Refer to nephrologist if
l Urinalysis blood or protein >1+ after
6 months
l Macroscopic haematuria or heavy
proteinuria at presentation
l Hypertension (see Hypertension
guideline)
Refer to rheumatologist if
l Atypical or rapidly resolving rash
Uncomplicated HSP
l GP follow-up in 12 weeks. Monthly
BP for 6 months and weekly urine
dipsticks until urine clear
l If persistent proteinuria/haematuria or
abnormal renal function, refer to
nephrologist
135
Investigations
l FBC, blood film and clotting
l CMV and EBV IgM
l Consider HIV, Hepatitis B and C if risk
factors
l If ITP, headache and neurological
signs, urgent CT scan of head
l Bone marrow aspiration unnecessary
unless:
l neutropenia or severe anaemia
l hepatosplenomegaly
l lymphadenopathy
l pallor and lassitude
l pain limb/abdomen
l limp
IMMEDIATE TREATMENT
l None regardless of platelet count,
unless life-threatening owing to
significant bleeding
l If significant bleeding (e.g.
uncontrollable epistaxis, GI
haemorrhage, intracranial bleed), give:
l platelets (see Blood and platelet
transfusions guideline)
l immunoglobulin 1 g/kg (see Trust
policy)
l If moderate bleeding e.g. prolonged
mucosal bleeds, give prednisolone
4 mg/kg (max for 4 days)
l Avoid aspirin and ibuprofen
l Reassure parents
l Discuss treatment with platelets with
haematologist in event of:
l essential operations
l emergency dental extractions
SUBSEQUENT MANAGEMENT
l 7580% resolve in 6 months
l favourable outcome irrespective of
treatment
l Avoid contact sports
l impossible to prevent fighting/rigorous
knockabout games at home
MONITORING TREATMENT
l FBC only if bleeding or increased
bruising
136
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Expires: November 2012
l Avoid NSAID's
l Avoid contact sports
l Investigate for autoimmune disease
and immune deficiency
l Treat only:
l profound thrombocytopenia
(<10 x 109/L) with repeated mucosal
bleeding
l older girls with menorrhagia
l trauma
l acute neurological signs
l If treatment indicated, give
prednisolone 12 mg/kg/day until
count responds
l reduce gradually
l must have bone marrow aspirate
before treatment
Issue 4
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Expires: November 2012
137
HAEMOPHILIA 1/3
INTRODUCTION
l Haemophilia is a serious disease.
Each child with haemophilia must:
l have open access
MANAGEMENT OF ACUTE
BLEEDING
l Patients present for treatment,
particularly when developing a
haemarthrosis before any physical
signs are present
138
l 50%
l 80100%
Issue 4
Issued: November 2010
Expires: November 2012
HAEMOPHILIA 2/3
Calculation of replacement factor
l Most boys with haemophilia receive
recombinant factor
l Calculate units of factor needed, X,
using following formula:
Other treatment
l On advice of consultant haematologist
for those with inhibitors to factors VIII
or IX
l Factor VIIa (recombinant: Novoseven)
90 micrograms/kg 2 hrly with frequent
review
Administration of factor
concentrate
l Give intravenously over about 3 min
l adverse reactions rare but include
anaphylactic shock
Duration of treatment
l Decided by local on-call haematologist
or designated tertiary haemophilia unit
(on-call haematologist). If in doubt, ask
DESMOPRESSIN IN MILD
HAEMOPHILIA A AND VON
WILLEBRANDS DISEASE
l Intranasally or IV
Patient selection
l Consider only in mild (NOT severe)
haemophilia A
Administration of desmopressin
l Intravenously: 0.3 micrograms/kg IV in
sodium chloride 0.9% 50 mL over
20 min. May be repeated after 12 hr
l Intranasally: 4 micrograms/kg IV once
l Side effects include hypertension
139
HAEMOPHILIA 3/3
VON WILLEBRANDS DISEASE
l More common than haemophilia
Tranexamic acid
l Anti-fibrinolytic agent
vWD Type
Type 1
Type 2A
Type 2B
Type 3
l
l
l
l
l
l
l
Desmopressin
l Treatment of choice in responsive
patients for spontaneous bleeding,
trauma and minor surgery
Advice
Most patients responsive
Some patients responsive
ask about previous challenge
DO NOT GIVE desmopressin
it causes platelet agglutination and thrombocytopenia
Not all responsive and some can be severe
ask about previous challenge
140
Issue 4
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Expires: November 2012
ANTIBIOTICS 1/1
EMPIRICAL ANTIBIOTICS
Once organism identified, change antibiotic to narrowest spectrum appropriate for
site of infection
Oral unless unavailable or IV stipulated; if not tolerating oral fluids use same
antibiotic IV
Pneumonia:
Community acquired
aged 5 yr
aged 5 yr
?aspiration
Mild
Severe
amoxicillin
amoxicillin +/- clarithromycin
Co-amoxiclav
Co-amoxiclav IV
Co-amoxiclav IV + clarithromycin IV
Co-amoxiclav IV + metronidazole
Piperacillin/tazobactam
Meropenem
Empyema
Co-amoxiclav IV
Allergy
l For rash with penicillin give cephalosporin:
l clarithromycin instead of amoxicillin
l cefuroxime instead of co-amoxiclav (+ metronidazole for aspiration)
l ceftazidime instead of piperacillin/tazobactam
l For anaphylaxis with penicillin or rash with cephalosporin give:
l clarithromycin instead of amoxicillin or co-amoxiclav
l aztreonam and vancomycin instead of piperacillin/tazobactam or meropenem
Meningitis
Sepsis from:
Community
Hospital
UTI: Mild
Severe
Osteomyelitis
and septic arthritis
Orbital cellulitis
Endocarditis
Penicillin allergy
Cefotaxime
Chloramphenicol IV
or ceftriaxone (aged >1 month) or vancomycin + rifampicin
+ amoxicillin (aged <3 months) (for anaphylaxis with penicillin or
cephalosporin)
Cefotaxime
Piperacillin/tazobactam
Co-amoxiclav
Co-amoxiclav IV
Flucloxacillin IV
Chloramphenicol IV
(for anaphylaxis with penicillin or
cephalosporin)
Aztreonam+ vancomycin
Trimethoprim
Gentamicin
Clindamycin
Cefotaxime
Chloramphenicol IV
Flucloxacillin IV
Vancomycin + gentamicin (low dose)
+ gentamicin (low dose)
Prosthesis or ?MRSA Vancomycin + rifampicin + gentamicin (low dose)
GI surgical prophylaxis Co-amoxiclav
Gentamicin + metronidazole
and treatment
e.g. peritonitis
Neonatal sepsis
1st line: benzylpenicillin + gentamicin (presenting <72 hr old)
Not responding to above after 24 hr and no organism isolated:
2nd line: flucloxacillin IV + gentamicin or (presenting >72 hr old)
Not responding to above after 24 hr and no organism isolated:
3rd line: cefotaxime + vancomycin
(CSF clear) piperacillin/tazobactam + vancomycin
Not responding to above after 24 hr and no organism isolated:
4th line: meropenem + vancomycin
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141
BITES 1/1
Prevention of infection after bites from
humans and other animals
Antibacterial prophylaxis
Type of bite
Specimen
Treatment
Duration
142
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Acute lymphadenitis
l Short history (usually <2 weeks)
l Neck mass with features of acute
inflammation
Subacute lymphadenopathy
l History variable
l Often non-tender but with overlying
erythema
Chronic lymphadenopathy
l Longer history (usually >1 month)
l No feature of acute inflammation
HISTORY
Symptoms
l Duration
l Symptoms of URTI
l Fever
l Weight loss
l Night sweats
l Eczema/skin infection
l Bruising
l Pallor
l Bone pain
l Pruritis
Social
l Contact with TB or cats
l Travel
EXAMINATION
l Site of node(s) (see figure 1)
l Size of node(s)
l ENT examination
l Skin especially eczema
l Axillae and groin for other nodes
l Abdomen for hepatosplenomegaly
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DIFFERENTIAL DIAGNOSIS
Acute unilateral
l Reactive
l URTI (Strep)
l skin infection (Strep, Staph)
l dental infection (anaerobes)
l Kawasaki (see Kawasaki disease
guideline)
l Cat scratch disease (Bartonella)
l Kikuchi-Fujimoto disease (histocytic
necrotising lymphadenitis)
Acute bilateral
l Reactive
l viral URTI
l EBV
Subacute
l Non-tuberculous mycobacteria
l Mycobacterium tuberculosis
Chronic
l Reactive
l Neoplasia
l lymphoma
l leukaemia
l soft tissue tumours
INVESTIGATIONS
l See flowchart
l Serology for Bartonella, toxoplasma,
CMV and EBV
l CXR
l Hilar lymphadenopathy significantly
increases likelihood of neoplastic
disease
l Ultrasound
l high sensitivity and specificity for
abscess formation in acute
lymphadenitis
l value in chronic lymphadenopathy for
assessing size, site, shape and
vascularity
l CT only if suspected deep neck space
infection
143
AT:
PT:
SM:
SC:
LC:
MC:
UC:
P:
144
Anterior triangle
Posterior triangle
Submandibular triangle
Supraclavicular triangle
Lower cervical chain
Mid cervical chain
Upper cervical chain
Parotid
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No
Yes
Fluctuant
Refer to
ENT
l Well
l Older child
l Small mass
Yes
No
Manage as
outpatient
Refer to
guideline
Admit
Yes
Kawasaki?
No
Pus
?atypical
mycobacteria
Solid
IV co-amoxiclav
for 24 hr
USS
Check
cultures
No
Improved?
Yes
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Discharge on
PO co-amoxiclav
145
Clinical
assessment
l All of:
l <1 cm
l mobile
l well child
l Any of:
l >3 cm
l supraclavicular
l constitutional symptoms
l generalised LN
l hepatosplenomegaly
l CXR
l USS neck
l FBC & film
l Serology for:
l EBV
l CMV
l Toxoplasma
l Bartonella
l Co-amoxiclav for
2 weeks
l CXR
l FBC
l U&E
Discharge
146
Yes
Improved or
positive
serology
No
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FEVER 1/3
This guideline applies until
underlying condition
diagnosed, at which point treat
child according to the guidance
for that condition
ASSESSMENT AND INITIAL
MANAGEMENT
IDENTIFYING RISK OF
SERIOUS ILLNESS
3 stages of clinical assessment
1. Identify life-threatening features
(utilising Airway, Breathing, Circulation
and Disability assessment)
2. Assess risk of serious illness (see
table Traffic light system for
assessment)
3. Attempt to identify source of
infection/features of specific serious
conditions
Intermediate risk
l Pallor reported by
carer
l Not responding normally
to social cues
l Wakes only with
prolonged stimulation
l Decreased activity
l No smile
l
l
l
l
Hydration
l Normal
Other
l No amber/red features
l
l
l
l
l
l
l
l
l
l
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High risk
147
FEVER 2/3
Child aged
<3 months
l Observe and
monitor:
l temperature
l heart rate
l respiratory rate
l
l
l
l
l
Perform:
full blood count
C-reactive protein
blood culture
urine test for urinary
tract infection
l if respiratory signs
present, chest X-ray
l if diarrhoea present,
stool culture
l Admit, perform
lumbar puncture and
start parenteral
antibiotics if child:
l aged <1 month
l aged 13 months,
appearing unwell
l aged 13 months,
with white blood cell
count of <5 or >15 x
109/L
l If no diagnosis
reached, manage
child at home with
appropriate care
advice
l Advise
parents/carers
when to seek
further attention
from healthcare
services
If any amber
features and no
diagnosis reached
l Perform:
l urine test for
urinary tract
infection
l full blood count
l blood culture
l C-reactive protein
l if fever >39C
and white blood
cell count >20 x
109/L chest
X-ray
l if child aged
<1 yr, consider
lumbar puncture
Child aged
3 months
l
l
l
l
Perform:
blood culture
full blood count
urine test for
urinary tract
infection
l C-reactive protein
l Consider (guided
by clinical
assessment):
l lumbar puncture
in children of all
ages
l chest X-ray
irrespective of
white blood cell
count and body
temperature
l serum
electrolytes
l blood gas
Wherever possible,
perform lumbar
puncture before
administration of
antibiotics
l Consider admission according to clinical and social circumstances and treat see
Subsequent management
l If child does not need admitting but no diagnosis has been reached, provide parent/carer with
verbal and/or written information on warning symptoms and how to access further healthcare
l Liaise with healthcare professionals (including out-of-hours) to ensure parent/carer has direct
access for further assessment of child
l Arrange follow-up appointment
148
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FEVER 3/3
Observations
l Measure and record in all febrile
children:
l temperature
aged <4 weeks electronic
thermometer in the axilla
aged >4 weeks infrared tympanic or
electronic thermometer in the axilla
l heart rate
IMMEDIATE TREATMENT
Antipyretic treatment
l Tepid sponging not recommended
Signs of shock
l Give immediate IV fluid bolus of
sodium chloride 0.9% 20 mL/kg. Give
additional boluses as necessary
SUBSEQUENT MANAGEMENT
l who is unrousable
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149
HEPATITIS 1/1
Follow-up for children diagnosed with
Hepatitis B or C
HEPATITIS C
HEPATITIS B
Diagnostic tests
Diagnostic tests
Yearly follow-up
l Clinical assessment
Yearly follow-up
l Clinical assessment
l LFT
l HBeAb
l Alpha-fetoprotein
If LFT abnormal, inform Regional Liver
Unit
150
l HCV PCR
l FBC
l Alpha-fetoprotein
5 yearly follow-up
l Abdominal ultrasound looking for
nodules or signs of portal
hypertension
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PEP
l <35 kg: Zidovudine AND lamivudine or
35 kg: Truvada 1 tab daily AND
l Kaletra [>35 kg 2 x (200/50 tab) 12 hrly]
l If index case has drug-resistant virus,
seek expert help
Dose
Formulation
Side effects
Intake
recommendation
Can be given with
Zidovudine (ZDV 180 mg/m2/dose
Caps. 100,
Neutropenia +/or AZT)
(max 250 mg)
250 mg Susp.
anaemia, nausea, food; capsules
can be opened
12 hrly
10 mg/mL
headache,
and dissolved in
hepatitis
water
myopathy, nail
pigmentation
Lamivudine (3TC) 4 mg/kg/dose
Tab. 100, 150 mg; Peripheral
Can be given with
12 hrly; max dose Susp. 10 mg/mL; neuropathy,
food
150 mg
nausea,
5 mg/mL (room
12 hrly
diarrhoea,
temp)
headache
Can be given with
Tab. 300 mg
Headache,
Truvada
1 tab daily
or without food
Tenofovir (TDF)
diarrhoea,
(TDF and FTC)
200 mg
nausea, renal
Emticitabine
tubular
(FTC)
dysfunction
2
Tab
200
mg
LPV/
Diarrhoea,
Give with or after
+
300
mg
LPV/m
Kaletra
headache,
food
50 mg RTV
75 mg RTV/m2
[lopinavir
12 hrly
Paed tab 100 mg nausea, vomiting
(LPV)/ritonavir
Caution in liver
LPV/25 mg RTV
Max dose 5 mL,
(RTV)]
disease
2 x 200/50 tab
12 hrly
Liq 5 mL =
400 mg LPV/
100 mg RTV
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151
FOLLOW-UP
l Before discharge, provide families
embarking on HIV PEP with:
152
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HOW
Who can test?
l rash (maculopapular)
l myalgia
l pharyngitis
l headache/aseptic meningitis
POST-TEST
HIV negative result: post-test
discussion
153
Neurology
AIDS-defining conditions
Pneumocystis pneumonia
Tuberculosis
Cerebral toxoplasmosis
Primary cerebral lymphoma
Cryptococcal meningitis
Progressive multifocal
leucoencephalopathy
Dermatology
Kaposis sarcoma
Respiratory
Oncology
Non-Hodgkins lymphoma
Gynaecology
Cervical cancer
Haematology
Ophthalmology
ENT
Cytomegalovirus retinitis
Other
154
IMMUNODEFICIENCY 1/2
RECOGNITION AND
ASSESSMENT
Previous history
l Recurrent fever
l Diarrhoea
l Delayed umbilical cord separation of
3 wks, omphalitis
l Severe adverse reaction to
immunisation e.g. BCGitis
l Unusually severe course of measles or
chickenpox
l Family history of any syndrome
associated with immunodeficiency,
(e.g. DiGeorge anomaly or WiskottIssue 4
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Physical examination
l Congenital abnormalities: dysmorphic
features, congenital heart disease,
situs inversus, white forelock
l Children who appear chronically ill,
underweight or short in stature
l Scarring or perforation of tympanic
membranes from frequent infection
l Periodontitis
l Enlargement of liver and spleen
l Hypoplastic tonsils and small lymph
nodes
l Lymphadenopathy
l Telangiectasia, severe eczema,
erythroderma, granuloma, acneiform
rash, molluscum, zoster
l Bronchiectasis, pneumatoceles
l Delayed 2ry dentition/skeletal fractures
Other investigations
l Haemolytic anaemia
l Neutropenia
l Eosinophilia
l Hypocalcaemia
Unusual organisms
l Viruses: CMV, EBV, VZV, warts
l Fungi: candida, aspergillus,
cryptococcus, pneumocystis, nocardia
l Protozoa: cryptosporidium, toxoplasma
l Bacteria: salmonella, giardia,
mycobacterium (inc BCG), serratia
l Recurrent infection with common
organisms: H. influenzae,
S. pneumoniae, N. meningitidis,
S. aureus
155
IMMUNODEFICIENCY 2/2
Table 1: Investigations
Investigations
Sample
Initial tests
FBC (note absolute lymphocyte
EDTA
count) and ESR
IgG, IgM, IgA
Clotted
IgG function (antibody response to Clotted
tetanus, Hib +/- pneumococcus)
Retest 4 wks after vaccination
Clotted
HIV antibody
Second-line tests (with immunology advice)
EDTA
Lymphocyte subsets
Lymphocyte proliferation
Enzyme assay (ADA, PNP)
Lithium heparin
EDTA
EDTA
EDTA
Clotted
SUBSEQUENT MANAGEMENT
l Avoid live vaccines (e.g. BCG, MMR
and varicella)
l Ensure that any blood products given
to patients with suspected or proven
T-cell immunodeficiency are irradiated
and CMV negative
l For specific infections, use same
antibiotics as in immunocompetent
patients, at higher recommended
dosage
l Obtain throat, blood and other culture
specimens before starting treatment
l Treat infectious episodes for longer
than usually recommended
(approximately double)
156
Volume
Minimum
Ideal
1.3 mL
4 mL
0.5 mL
0.5 mL
4 mL
4 mL
0.5 mL
4 mL
1 mL
Haematology
4 mL
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Other features
l Most common in children aged <5 yr
l Atypical cases may not fulfil all the
above criteria
Investigations
None is diagnostic
l CRP
l ECG
IMMEDIATE TREATMENT
l Aspirin 7.512.5 mg/kg orally 6 hrly
until afebrile or a minimum of 2 weeks
=...mL/hr
=...mL/hr
=...mL/hr
=...mL/hr
Duration
30 min
30 min
30 min
To completion
157
158
OUT-PATIENT MANAGEMENT
l No aneurysms at 6 weeks
echocardiogram
l stop aspirin
l no restriction on activity
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MALARIA 1/2
A medical emergency: immediate treatment essential
Diagnosis
l Fever
l febrile neonate or infant whose mother has travelled to a malarial area in pregnancy
Clinical features
Non-specific
l Fever
l Malaise
l Headache
l Sweating
l Diarrhoea
l Vomiting
l Abdominal pain
l Splenomegaly
l Anaemia
l Thrombocytopenia
l Jaundice
Investigations
l EDTA blood sample sent to
haematology for an urgent thick blood
film
l 3 blood films 12 hr apart
If malaria is diagnosed on
blood film, but type unclear,
treat as falciparum malaria
Admit all patients with definite
or possible falciparum malaria
to hospital as they can
deteriorate rapidly into a coma
SEVERE (COMPLICATED)
MALARIA
Anti-malaria treatment
l Quinine dihydrochloride IV
l loading dose 20 mg/kg max 1.4 g as
infusion diluted to 2 mg/mL (sodium
chloride 0.45% + glucose 5%) over
4 hr (NEVER as IV bolus)
l then 8 hr after start of loading dose,
10 mg/kg infusion (max 700 mg) over
4 hr every 8 hr
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CEREBRAL MALARIA
Impaired level of consciousness
l Correct hypoglycaemia
l Monitor GCS, reflexes, pupils
l Plan for intubation and transfer to
PICU if:
l signs of raised ICP
l persisting shock after 40 mL/kg fluid
l or pulmonary oedema
159
MALARIA 2/2
TREATMENT OF UNCOMPLICATED FALCIPARUM MALARIA
(no clinical features of severe malaria)
l If the child can tolerate oral intake:
l Malarone (proguanil with atovaquone) once a day for 3 days
Weight (kg) 58
910
1120
2130
3140
>40
Dose
3 paed
tablets
1 adult
tablet
2 adult
tablets
3 adult
tablets
4 adult
tablets
2 paed
tablets
G6PD-deficient patients
Treatment of non-falciparum
malaria
l If chloroquine resistance suspected
then refer to non-complicated
falciparum management
l Chloroquine oral 10 mg (base)/kg
initial dose (max 620 mg) then,
5 mg/kg (max 310 mg) after 68 hr
then once daily for 2 days
l Then give primaquine oral
250 microgram/kg (max 15 mg) daily
for P. ovale and 500 microgram/kg
(max 30 mg) daily for P. vivax for
14 days
160
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MENINGITIS 1/4
RECOGNITION AND
ASSESSMENT
If aged <28-days-old see Neonatal
meningitis in Neonatal Guidelines
Symptoms, especially in
infants, are often vague and
non-specific. Be alert
Symptoms and signs
l Pyrexia
l Petechial rash
l Evidence of raised intracranial
pressure in the older child
l disc oedema (often late sign), any
localising neurological features,
reduced conscious level
l Neck stiffness
l Kernig's sign positive
l Irritability
l Focal neurological signs including
squints
l Infants:
l poor feeding
l vomiting
l irritability
l fever
l fits
l full fontanelle (unless dehydrated)
l Older child may also have:
l severe headache
l photophobia
l confusion
l lower backache
Differential diagnosis
l If rash or severely ill, consider
Meningococcal septicaemia
l Look for signs of viral meningitis e.g.
resolving mumps
l It is not possible to differentiate viral
from bacterial meningitis clinically
l Other intracranial sepsis
l Encephalitis
l Systemic sepsis
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l Malaria in travellers
l Other causes of confusion or raised
intracranial pressure
INVESTIGATIONS
Lumbar puncture
If any doubt about need for
lumbar puncture (LP) discuss
with consultant
l Perform LP before giving antibiotics if
child stable, do not delay antibiotics by
>1 hr
l Discuss with consultant if any of
following:
l signs suggesting raised intracranial
pressure
- GCS <9 or drop >2
- relative bradycardia and hypertension
- focal neurological signs
- abnormal posture or posturing
- unequal, dilated or poorly responsive
pupils
- papilloedema
- abnormal dolls eye movements
l shock
l extensive or spreading purpura
l convulsing
l coagulopathy, on anticoagulants or
platelets <100 x 109/L (if already
obtained do not wait for results
otherwise)
l local infection over lumbar spine
l respiratory insufficiency
l coagulopathy or thrombocytopenia
suspected (e.g. purpuric rash)
l If no clinical response after 48 hr of
therapy, consider repeat LP
Specimens
l 1 fluoride tube (and 4 CSF bottles)
l If tap traumatic, may need more
samples
l If insufficient CSF discuss priorities
with microbiology
161
MENINGITIS 2/4
Table 1: Collection of specimens (stated volumes represent minimum required)
Department
Biochemistry
Microbiology
Virology
Interpretation of cerebrospinal
fluid results
l White cell count showing
polymorphonuclear leucocytosis usually
indicative of bacterial meningitis but can
also be seen in viral meningitis
l lymphocytosis can occur in partiallytreated pyogenic, TB and viral
meningitis and inflammatory conditions
Other
l FBC and differential WBC
IMMEDIATE TREATMENT
Corticosteroids
CT scan
l Not routine, does not exclude raised
intracranial pressure
l indicated in presence of focal
neurological signs to rule out space
occupying lesion
162
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MENINGITIS 3/4
Antibiotics
Start immediately without
waiting for identification of
organisms or sensitivities
l Cefotaxime or ceftriaxone until certain
it is not bacterial meningitis
Intensive care
l Inform PICU if:
MONITORING TREATMENT
l In a semi-conscious patient, monitor
following hourly until improvement
evident:
l respiratory rate
l pulse and BP
SUBSEQUENT MANAGEMENT
Length of antibiotic course
Anticonvulsants
l Drugs of choice if child has seizures
(prophylaxis not recommended):
l phenytoin
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l Meningococcus: 7 days
163
MENINGITIS 4/4
Steroids
Continue dexamethasone if:
l CSF WCC >1000/microlitre
l CSF protein >1 g/L
Eradication treatment
l Meningococcal meningitis
Fluid restriction
l Restrict fluid to 80% maintenance if:
l severe illness
l hyponatramia
Public health
l Inform Public Health consultant of a
case of suspected meningitis
164
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NOTIFIABLE DISEASES
Admitting doctor is required to notify
suspected or confirmed cases of the
following to Health Protection Unit within
24 hr of presentation:
l Cluster or outbreak suspected (two or
more cases epidemiologically linked)
l Any other case where the potential for
transmission is significant (e.g. highly
infectious)
l Where contacts are particularly
susceptible (e.g. healthcare worker,
school)
l Where public health action is known to
be effective (e.g. prophylaxis,
immunisation)
l Other infections or contaminations (e.g.
chemical) not listed below if potential
risk of further harm
l Acute encephalitis
l Acute poliomyelitis
l Anthrax
l Cholera
l Diphtheria
l Dysentery (amoebic and bacillary)
l Food poisoning (or suspected food
poisoning: inform public health if
acquired abroad or if family member is
a food handler or healthcare worker)
l Leprosy
l Leptospirosis
l Malaria
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l Measles
l fever, maculopapular rash for 3 days
and two or more of the following:
Kopliks spots, coryza, conjunctivitis,
raised measles IgM, measles
encephalitis or pneumonitis. Inform
public health of MMR or measles
vaccination history
l Meningitis (viral, bacterial or fungal)
l Meningococcal septicaemia (without
meningitis)
l Mumps
l Ophthalmia neonatorum
l Paratyphoid fever
l Plague
l Rabies
l Relapsing fever
l Rubella
l rash and occipital lymphadenopathy or
arthralgia (if not parvovirus), or
congenital rubella or raised IgM to
rubella. Inform public health of MMR
vaccine history
l Scarlet fever
l tonsillitis, fever, rash with either culture
of Streptococcus pyogenes from throat
or raised ASO or anti-DNaseB titre
l Smallpox
l Tetanus
l Tuberculosis
l TB diagnosed on X-ray, microscopy or
culture from any source (i.e. not just
sputum)
l (atypical mycobacterial infection or
patients given chemoprophylaxis but
not thought to have TB are not
notifiable)
l Typhoid fever
l Typhus
l Viral haemorrhagic fever
l Viral hepatitis
l either diagnosed clinically or by positive
serology. Inform public health if
acquired abroad or in UK, risk factors
and immunisation against Hepatitis A
and B
165
Non-statutory notifiable
diseases
It has been agreed that, although they are
not statutorily notifiable, the following
diseases will nevertheless be reported to
the consultant in communicable disease
control:
l AIDS/HIV infection
l Legionnaires disease
l Listeriosis
l Psittacosis
l Cryptosporidiosis
l Giardiasis
l Creutzfeldt-Jakob disease and other
prion diseases
l SARS
CONTACT DETAILS
Contact details for your nearest HPU can
be found on the Health Protection Agency
website (www.hpa.org.uk)
West Midlands
Birmingham and Solihull HPU
01384 454300
01905 760024
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Orbital
Normal vision
Visual impairment
(red-green colour differentiation lost early)
Proptosis
Chemosis
Ophthalmoplegia
Preceding sinusitis
Definition
l Infection of soft tissues surrounding the
eye
l
l
l
l
Complications
Intracranial abscess
Meningitis
Cavernous sinus thrombosis
Periorbital abscess
Investigations
MANAGEMENT
Preseptal peri-orbital cellulitis
Orbital cellulitis
l Urgent ophthalmology review within 4 hr
l ENT review
l IV cefotaxime or ceftriaxone
l If toxaemic add clindamycin
l If history of anaphylaxis to penicillin
give aztreonam and vancomycin
l Consider surgical drainage
l if improving, convert to oral high dose
co-amoxiclav
l if penicillin allergy give clindamycin
l Total duration of treatment (including
IV) 21 days
Intracerebral complications
Sinusitis
l Follows viral URTI (80%) or allergy
l URTI symptoms >10 d and >1 of:
l nasal congestion and discharge
l persistent cough (often nocturnal)
l Treat with co-amoxiclav oral high dose
l Severe if also:
l ill, temperature >39C, purulent
discharge
l Urgent CT, ENT, neurosurgical review
167
l Fever
l Loss of function
l Pain in bone or joint
l Restricted range of movement
l Soft tissue swelling
l Point tenderness of bone
l Effusion
Further investigations
Perform as soon as possible
(must be within 36 hr)
l If plain X-ray normal, infection clinically
localised and urgent MR is available:
l consultant paediatrician or orthopaedic
surgeon to authorise urgent MR of bone
l if deep sedation or general
anaesthetic required, contact
paediatric anaesthetist on-call
l If plain X-ray normal, and infection
clinically localised and MRI not available,
request ultrasound scan of bone
l If localising signs poor or possible
multifocal infection, request bone scan
l If cardiac murmur or multifocal Staph.
aureus, request echocardiogram
IMMEDIATE TREATMENT
Previous history
l Ask about:
l duration of symptoms
l injuries
l fever
Urgent Investigations
l FBC
l ESR
l CRP
l Blood culture (before antibiotics)
l If cause of fever uncertain, collect
other specimens (e.g. urine) for culture
before antibiotics
Osteomyelitis
Septic arthritis
l Admit
l Nil-by-mouth and maintenance fluids IV
l Bed rest
l Refer immediately to orthopaedic and
paediatric registrar on-call
l confirm they will assess child within
4 hr of admission
l Early involvement of on-call consultant
orthopaedic surgeon
Antibiotics
Analgesia
l If necessary initially, to allow splintage
use morphine IV (see Analgesia
guideline)
l Elevate and splint affected limb
l plaster backslab for peripheral joints
l rest in skin traction on a pillow for
central joints
Surgery
Ask parent(s) to stay with child until
consent obtained
l Resuscitate severe sepsis
l Emergency theatres to be alerted as
soon as possible (must be within 36 hr
of admission)
l Contact:
l anaesthetic office to arrange paediatric
anaesthetist
l orthopaedic RSO to book patient onto
planned emergency list
l consultant paediatrician and
orthopaedic surgeon
l transfer to Trauma Theatre (nurse
escort)
SUBSEQUENT MANAGEMENT
Inform paediatric orthopaedic surgeon
and paediatrician
Early-presenting osteomyelitis
l If IV antibiotics started within 24 hr of
onset of symptoms
l If abscess drained and full
debridement achieved with a good
clinical response as above, follow
Uncomplicated septic arthritis but
continue for 4 weeks minimum
Established osteomyelitis or
complicated septic arthritis
170
MONITORING TREATMENT
l Peripheral colour, warmth, movement
of affected limb: hourly for first 4 hr
then 4 hrly for 24 hr
l Respiratory rate, pulse, temperature
4 hrly
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BLOOD INVESTIGATIONS
l FBC
l CRP (+/ ESR)
l Blood culture (4 mL minimum unless neonatal 2 mL)
IMAGING AVAILABLE?
OM
l MR (gold standard)
l Ultrasound (if no urgent MR and expertise available)
l Plain X-ray (baseline)
SA
l Ultrasound
l Consider need for 99Tc bone scan
Aged 3 months to 5 yr
IV cefuroxime
50 mg/kg 8 hrly
Aged 6 yr
IV flucloxacillin 50 mg/kg 6 hrly
(max 2 g 6 hrly)
OR
IV clindamycin 10 mg/kg 6 hrly
(max 1.2 g 6 hrly)
Daily clinical review, monitor fever, CRP daily until improving, consider surgery indications
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171
BLOOD INVESTIGATIONS
l FBC
l CRP (+/ ESR)
l Blood culture (4 mL minimum unless neonatal 2 mL)
IMAGING AVAILABLE?
OM
l MR (gold standard)
l Ultrasound (if no urgent MR and expertise available)
l Plain X-ray (baseline)
SA
l Ultrasound
l MR
l Consider need for 99Tc bone scan
Aged 3 months to 5 yr
IV cefuroxime
50 mg/kg 8 hrly
Aged 6 yr
IV flucloxacillin 50 mg/kg 6 hrly
(max 2 g 6 hrly)
OR
IV clindamycin 10 mg/kg 6 hrly
(max 1.2 g 6 hrly)
OM and SA
6 weeks to many months therapy may be
required, tailored to individual response.
CRP (+/ ESR) normal
OM and SA
6 weeks to many months therapy may be
required, tailored to individual response. CRP
(+/ ESR) normal
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Yes
No
Treat
underlying
illness
Mechanical?
l Local trauma
l Superior vena cava distribution after
vomit/cough
Yes
No
Rash progressing?
Yes
No
l Check FBC
l Coagulation screen
l Blood culture
l CRP
Treat as
necessary
Yes
Abnormal platelets/coagulation
screen?
No
l
l
l
l
l
Observe over 46 hr
Registrar review
Discharge if:
no purpura
patient remains well with nonprogressive rash
l WCC 515 and CRP <10
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173
Investigations
l FBC and differential
l Blood culture (important to put in
maximum amount of blood bottle
designed to take)
l Blood gas and lactate
l Blood glucose
l Meningococcal PCR
l Group and save
l Clotting profile
l U&E, LFT, Ca++, Mg++, PO4, CRP
l Save for serum cortisol
If purpuric rash
l Treat immediately
Meningococcal septicaemia
l Assess severity of disease on
Glasgow Meningococcal Septicaemia
Prognostic Score:
Glasgow Meningococcal Septicaemia Prognostic Score (GMSPS)
Criteria
Systolic BP (cuff width >2/3 upper arm length)
if <75 mmHg in child aged <4 yr
or <85 mmHg in child aged >4 yr
Skin/rectal temperature difference (measure for 2 min)
if axilla/rectal temperature difference >3oC
Modified coma scale (see Glasgow coma scale guideline)
if initial score <8
or deterioration of 3 points at any time
Deterioration in last hour (subjective)
ask parents or nurse; if yes, score
Neck stiffness
if no neck stiffness, score
Extent of purpura
widespread ecchymoses or extending lesions on review
Base deficit
if deficit >8 mmol/L
Maximum score
174
Score
3
3
3
2
2
1
1
15
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Differential diagnosis
l Toxic shock syndrome
l Malaria
IMMEDIATE TREATMENT
l Ensure patent airway and adequate
breathing
l Administer 15 L/min O2 through a
reservoir mask
l if airway and breathing remain
compromised despite simple airway
manoeuvres and 100% O2, contact
consultant and anaesthetist on-call
l Assess circulation, if severe sepsis or
extensive rash, insert two large IV
cannulae or establish intraosseous
access and give human albumin 4.5%
20 mL/kg or if not immediately available
sodium chloride 0.9% over 510 min
Antibiotics
l Give IV cefotaxime 50 mg/kg (max 3 g
6 hrly) over 20 min
l if history of anaphylaxis to
cephalosporin give chloramphenicol IV
or vancomycin and rifampicin if no IV
chloramphenicol immediately available
l if pseudomonas suspected add
gentamicin
l if MRSA suspected, add vancomycin
l if anaerobic infection suspected, add
metronidazole
l if multiple-resistant organisms give
meropenem
l If hypotension continues, peripheries
remain cool, rash continues to evolve,
and capillary refill >2 sec, give further
human albumin 4.5% or sodium
chloride 0.9% 20 mL/kg over 510 min
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SUBSEQUENT MANAGEMENT
Circulation still compromised
l Contact paediatric consultant and
anaesthetist on-call and inform PICU
l Give further human albumin 4.5% or
sodium choride 0.9% 20 mL/kg
boluses if hypotension continues and
start inotropes
l Dopamine 520 microgram/kg/min
(7.5 mg/kg in 50 mL sodium chloride
0.9% at 28 mL/hr peripherally)
l start at 5 microgram/kg/min
l increase in 5 microgram/kg/min
increments every 5 min
l up to 20 microgram/kg/min as required
l If still hypotensive, start adrenaline
0.1 microgram/kg/min (0.3 mL/kg of
1:1000 in 50 mL sodium chloride
0.9% at 1 mL/hr)
l If still hypotensive, give hydrocortisone
0.25 mg/m2 6 hrly
Reassess ABC
l If still unstable, arrange immediate
intubation with senior anaesthetist
l prepare atropine 20 microgram/kg
(max 600 microgram)
l if no neck stiffness, ketamine 1 mg/kg;
if neck stiffness, thiopental sodium
3 mg/kg
l suxamethonium 2 mg/kg
l then morphine 20 microgram/kg/hr
(1 mg/kg in 50 mL sodium chloride
0.9% at 1 mL/hr)
l and midazolam 12 microgram/kg/min
(6 mg/kg in 50 mL sodium chloride
0.9% at 0.51 mL/hr)
l and vecuronium 1 microgram/kg/min
(1.5 mg/kg in 25 mL sodium chloride
0.9% at 1 mL/hr)
l Site nasogastric tube and urinary
catheter
l Prepare for central venous line with
portable ultrasound
175
MONITORING
l Monitor the following every 30 min for
first 2 hr, hourly for next 2 hr, then 4 hrly:
l conscious level
l temperature
l respiratory rate
l heart rate
l BP
l capillary refill time
l Monitor urine output hourly
l Monitor blood glucose and electrolytes
6 hrly until stable. Treat hypoglycaemia
with bolus IV glucose
l Monitor clotting screen 12 hrly. Treat
deranged clotting with FFP 10 mL/kg IV
176
SUBSEQUENT MANAGEMENT
l Adjust antibiotic treatment once culture
results available
l if meningococcal or no organism
identified give 7 days: cefotaxime
50 mg/kg 6 hrly IV
l or ceftriaxone 80 mg/kg IV daily, over
3060 min (not with calcium IV; not
aged <3 months)
l Treat S. aureus sepsis for 2 weeks
l Give antibiotics to treat carrier states in
haemophilus sepsis (see Meningitis
guideline)
l Avoid enteral feeds until acute shock
has resolved
l Do not hesitate to contact consultant
paediatrician on-call for advice
Public health
l Meningococcal: inform Public Health
consultant available 24 hr/day
l Public Health Department will arrange
prophylaxis for close contacts
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TUBERCULOSIS 1/3
Latent infection
l Contact with TB
l Asymptomatic
l Normal CXR
l Mantoux positive (15mm with BCG/
6 mm no BCG)
l or Interferon gamma positive
l For chemoprophylaxis and all aged
<2 yr discuss with specialist
RECOGNITION AND
ASSESSMENT
History is most important factor
in diagnosing tuberculosis
Symptoms
Suspect TB when following symptoms
persist for weeks:
l Weight loss +/ cough
l Persistent, non-remitting cough for 24
weeks
l Failure to thrive
l Lack of energy
l Fever and sweats
l Painless lymph nodes, especially if
matted
l Headache or irritability for >1 week
l Limp, stiff back, swelling of joint
l Swollen abdomen
Signs
INVESTIGATIONS
l Chest X-ray: look for hilar
lymphadenopathy, apical consolidation,
pleural effusion, miliary nodules
l If large matted nodes present, arrange
ultrasound scan, then biopsy. Ask
surgeon to send for mycobacterial
culture and histology
l Urinalysis: if blood and leucocytes
present, send for smear and culture
l non-tuberculous acid-fast bacteria
common in urine
l FBC, LFTs
l Tuberculin skin test:
l Mantoux tests: use tuberculin PPD
2 units (0.1 mL of 2 units/0.1 mL)
intradermally
l can be negative in miliary TB
l avoid if other tests positive or definite
clinical diagnosis of TB
TUBERCULOSIS 2/3
l do not send saliva
l Discuss broncho-alveolar lavage for
AFB and TB culture via bronchoscopy
with respiratory consultant
IMMEDIATE MANAGEMENT
l Admission not mandatory but useful to
ensure compliance with treatment. If
supervision can be guaranteed, allow
treatment at home
l Pre-pubertal children are not an
infection risk but their families may be
l notify case to public health and
infection control
l Inform Public Health through TB clinic,
who will organise chest X-ray and
Mantoux for all close and visiting
contacts
l Advise anyone with cough to avoid
visiting ward
178
Drugs
l Round up doses to give easily
measured volumes of syrup or
appropriate strengths of tablet.
Re-calculate doses with weight gain
l Supplement pyridoxine if breastfed
and/or malnourished
l Isoniazid: 10 mg/kg/day up to max
300 mg
l (suspension; 50 mg, 100 mg tab)
l Rifampicin: 10 mg/kg/day up to max
450 mg if <50 kg; 600 mg 50 kg
l (suspension; 150 mg, 300 mg tab)
l Pyrazinamide: 35 mg/kg/day up to max
1.5 g if <50 kg; 2 g 50 kg
l (crush 500 mg tablets)
l Ethambutol: 15 mg/kg/day (crush
100 mg, 400 mg tablets)
l check renal function first, do not round
dose up
l Consider drug combinations (e.g.
Rifinah, Rifater) if at all possible to
ensure compliance (see BNFc)
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TUBERCULOSIS 3/3
Presentation
Respiratory TB: lungs,
pleural cavity,
mediastinal lymph nodes
or larynx
Meningeal TB
Treatment
Rifampicin and isoniazid for 6 months
Pyrazinamide and ethambutol for 1st 2 months
SUBSEQUENT MANAGEMENT
l HIV test
MONITORING TREATMENT
l Check LFT only if vomiting, nausea,
lethargy, jaundice, etc
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179
INVESTIGATIONS
l If all history/examination
unremarkable, no investigations
needed
l If difficulty in closing eye,
ophthalmology referral
l Altered taste
l Facial pain
History
l History of prior viral infection may be
present
l Abrupt onset with no progression
Examination
l Full neurological examination,
including other cranial nerves, and
fundoscopy
IMMEDIATE TREATMENT
l If difficulty in closing eye, provide eye
patch and hypromellose eye drops
l If no other signs, no other treatment
necessary
l If vesicles suggest HSV, prescribe
aciclovir, test for immune deficiency
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EPILEPSY 1/5
DEFINITIONS
l Seizures/convulsions: paroxysmal
disturbance of consciousness,
behaviour, motor function, sensation
singly or in combination
l Epilepsy: recurrent seizures without
any provoking factor and happening in
different situations
l Seizure type: (focal or generalised or
any other type) based on history and
EEG
l Try to categorise into one of epilepsy
syndromes
RECOGNITION AND
ASSESSMENT
Seizure types
Generalised
l Tonic-clonic/tonic
l Clonic
l Atonic
l Absence
l Myoclonic
Focal
l Without impairment of consciousness
(focal motor, sensory or other types)
l With impairment of consciousness
(previously known as complex partial)
l Focal with secondary generalisation
(clinically look like generalised
seizures) history of aura, Todds
paralysis, focal features on EEG
Underlying cause
l In most cases epilepsy is idiopathic but
a few cases have an underlying cause
l actively look for the cause to guide
prognosis, other treatment and
recommendation for epilepsy surgery
EPILEPSY SYNDROMES
Identification
l Based on:
l seizure type
l age of onset
l neurodevelopmental status
l appearance of EEG ictal and interictal
EPILEPSY 2/5
Juvenile absence epilepsy
l Usually presents after age 910 yr
l Absence frequency is less than in
childhood absence epilepsy
l Cluster after awakening
l 90% of children have generalised
seizures in the same period while they
have absences
l EEG faster spike and wave
Panayiotopoulos syndrome
l Younger children (peak age 5 yr)
l Autonomic seizures and behavioural
disturbances usually nocturnal
l Usually starts with vomiting and child
initially conscious
l Subsequent deviation of eyes to one
side, impaired consciousness or may
end in hemiclonic seizure or (rarely)
generalised seizure
l Child looks unwell, unresponsive
l Other autonomic features very
common (e.g. dilated pupils, pale skin
or flushing, incontinence)
182
INVESTIGATIONS
Indications for EEG
l Clinically diagnosed epilepsy
l After an episode of status epilepticus
l Unexplained coma or encephalopathy
l Suspicion of non-convulsive status in
children with learning difficulties and
epilepsy
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EPILEPSY 3/5
Other investigations
l Sleep or sleep-deprived EEG useful in
all children in whom there is a high
clinical suspicion but awake EEG normal
l sleep EEG useful to pick up some
focal/generalised epilepsies and sleepdeprived EEG useful in generalised
epilepsies in young adults including
JME. Perform sleep EEG with melatonin
l Video telemetry useful if diagnostic
dilemma, pseudoseizures or before
surgery
l Drug levels phenytoin, phenobarbitone
(other anticonvulsants only if concerns
about compliance and overdose)
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TREATMENT
General guidelines
l Discuss treatment with a consultant
before starting
l Start antiepileptic only if diagnosis
certain (two or more unprovoked
seizures)
l Preferably after initial EEG results
obtained
l Start with small dose and build up to
half maintenance. If seizures continue,
increase to full maintenance
l Increase dose stepwise every
23 weeks
EPILEPSY 4/5
Discussion with child and
parents
Table 1: Drugs of first, second and third choice in treatment of seizure types
Seizure type
First
Generalised epilepsy Sodium valproate
OR
Carbamazepine
Childhood absence
Sodium valproate
Ethosuximide
epilepsy
Focal epilepsy
including TLE
Infantile spasms
Carbamazepine
Second
Carbamazepine
OR
Sodium valproate
Lamotrigine*
Sodium valproate
Lamotrigine
Topiramate
Levetiracetam
Prednisolone/tetracosactide Sodium valproate
Nitrazepam
OR
Vigabatrin
Third
Lamotrigine*
Levetiracetam
Topiramate
Levetiracetam
Topiramate
Clobazam
Phenytoin
Trial of pyridoxine
Epilepsy in adolescence
additional factors to be
considered
l Compliance
l Career choices
l Driving
l Contraception and pregnancy,
including pre-pregnancy counselling
l Alcohol and drugs
OUT-PATIENT MANAGEMENT
FURTHER OPINION/REFERRAL
TO SPECIALIST SERVICE OR
TERTIARY CENTRE (NICE
GUIDELINES)
SUBSEQUENT MANAGEMENT
184
Refer immediately
l Behavioural or developmental
regression
l Epilepsy syndrome cannot be
identified
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EPILEPSY 5/5
Refer soon
l When one or more of the following are
present:
l child aged <2 yr
l seizures continuing despite being on
AED (anti-epileptic drug) for 2 yrs
l 2 AEDs have been tried and are
unsuccessful
l risk of unacceptable side effects of
medication
l unilateral structural lesion
l psychological or psychiatric comorbidity
l diagnostic doubt about seizure type
and/or syndrome
Refer
l Refer specific syndromes such as:
l Sturge-Weber syndrome
l Rasmussens encephalitis
l Hypothalamic hamartoma
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WITHDRAWAL OF
ANTIEPILEPTIC DRUGS
185
Vascular access?
Yes
No
Lorazepam
0.1 mg/kg IV/IO (max 4 mg)
over 6 min (dilute 1:1 with
sodium chloride 0.9%)
Diazepam PR
OR Midazolam buccal
(see table below for exact dose)
10 min
10 min
YES
Lorazepam
0.1 mg/kg IV/IO
Vascular access?
10 min
No
Paraldehyde PR
50:50 ready mixed solution or diluted with equal volume of olive oil
(see table below for exact dose, expressed as volume of paraldehyde)
Diazepam (rectal)
Aged 1 month2 yr: 5 mg
Aged 212 yr:
Aged >12 yr:
186
Midazolam (buccal)
Age <6 months:
300 microgram/kg (max 2.5 mg)
Paraldehyde (rectal)
Aged 13 months: 0.5 mL
Aged 36 months:
1 mL
Aged 6 months1 yr: 1.5 mL
Aged 12 yr:
2 mL
Aged 25 yr:
34 mL
510 mL
Age 518 yr:
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CLINICAL HISTORY
l Adequacy of cough and swallowing
ASSESSMENT
l May not show overt signs of
respiratory distress such as
tachypnoea, recessions and use of
accessory muscles even in respiratory
failure
l Assess adequacy of chest wall
excursion and cough
l SpO2 in air
l ECG
MANAGEMENT
l If unwell, on long-term
corticosteroids, double usual daily
dose of steroids for 23 days. If
unable to tolerate oral steroids, use IV
hydrocortisone
187
Fractures
l Analgesia
l Orthopaedic consultation
Malignant hyperthermia
Malignant hyperthermia is a
medical emergency
l Occurs following general anaesthesia
and may be first presentation of a
neuromuscular disorder
Cardiac failure
l Fluid restriction
l Diuretics
188
Issue 4
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Eye opening
Spontaneously
To speech
To pain
Never
Score
4
3
2
1
Eye opening
Spontaneously
To speech
To pain
Never
Score
4
3
2
1
Score
6
5
4
3
2
1
Score
6
Score
5
4
3
2
1
Score
5
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5
4
3
2
1
4
3
2
1
189
NON-ACCIDENTAL INJURY
Definition
Physical abuse may involve hitting,
shaking, throwing, poisoning, burning or
scalding, drowning, suffocating or
otherwise causing physical harm to a child.
Physical harm may also be caused when a
parent fabricates the symptoms of, or
deliberately induces, illness in a child
l Recurrent injuries
l Evidence of other forms of abuse (e.g.
failure to thrive, neglect)
l Previous evidence of injury or neglect
(check if child known to local authority
childrens social care or is the subject
of a child protection plan)
Referrals
l Discuss referrals by GP with
consultant before arranging medical
assessment by on-call team
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How
l Record findings accurately during or
immediately after examination, using a
dedicated child protection proforma
with body charts if possible
l Complete and sign each page and
include:
l full family history
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EMOTIONAL ABUSE
Recognition and assessment
Definition
l Habitual harassment of a child by
disparagement, criticism, threat and
ridicule
Presentation
l Part of the differential diagnosis if a
child presents with the following nonspecific behaviours:
192
l unhappy
l disturbed
l poor concentration leading to learning
difficulties/school failure
l poor social interactions
l unable to play
l problems with attachment to parents
or caretakers
Assessment
l Assessment is complex and requires a
multidisciplinary approach
l social care take the investigative lead
NEGLECT
Neglect may not always be
intentional (e.g. parental mental
health problems)
Recognition and assessment
Definition
l Neglect is persistent failure to meet a
childs physical and/or psychological
needs
l Lack of care of physical needs that
can result in failure to thrive
Presentation
l Child's appearance
l note condition of clothing, hair, skin
l Growth
l height, weight, serial measurements to
check growth rate
l head circumference
l mid-upper arm circumference
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SUBSEQUENT MANAGEMENT
l Majority of children seen will be
allowed home if it is safe and after
discussion with social care
Communication is vital
l Send written report to GP, without
delay with a copy for social care and
police
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193
Presentation
Referrals
194
Forensic sampling
l Depending on local arrangements, the
police will determine whether this is
performed by a paediatrician trained in
forensic sampling or by a Forensic
Medical Examiner (FME)
l The FME will have forensic kits to take
necessary specimens for tests on
blood, semen, etc
Consent
Carers with parental
responsibility and child
(depending on age and
understanding) must give their
consent (usually written) for
examination to take place. If
consent not forthcoming, social
care may obtain a legal order
giving permission for child to
be examined. In an emergency,
consent to treat is not required
l An examination of this nature requires
preparation with due regard to child
l a young child may not comprehend
what is happening to him/her and there
is a risk that the investigation may be
as traumatic as the alleged incident
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History
l Incident or symptoms
l where referral made from social care
or Police Child Protection Teams, the
child may have already given a full
history, often on video, with
appropriate non-leading questions.
Discuss this information at beginning
of history and examination. If further
clarification required, use non-leading
questions and record all questions and
responses verbatim
l General health and emotional wellbeing, with particular emphasis on
genito-urinary or bowel symptoms (e.g.
constipation and secondary enuresis)
l Past medical history, including A&E
attendances
l Developmental history or school
progress
l Medication and immunisation history
l Family history (other children) may
require assessment. Complete a
genogram
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Examination
l Purpose of medical examination is to:
l detect traumatic or infective conditions
that may require treatment
l evaluate the nature of any abuse
l secure forensic evidence
l reassure the child
l start process of recovery
Record
l General health
l Growth: height, weight and sexual
maturity, plotted on a centile chart
l Developmental, emotional and
behavioural assessment
l Evidence of non-genital trauma (e.g.
bruises) or neglect
l Evidence of genital and anal trauma
(see below)
l A variety of signs can be associated
with sexual abuse that will vary with:
l type of abuse
l age of child
l degree of force used
l use of lubricant
l presence of infection
l time since last assault
195
Communication is vital
INVESTIGATIONS
Consider:
l Mid-steam urine
l Pregnancy test. If assault within 72 hr,
offer post-coital contraception
l levonorgestrel 1.5 mg stat dose (needs
to be prescribed if aged <16 yr)
l Forensic tests (FME to determine)
l Photos/video recordings obtained with
a colposcope, stored in accordance
with local policy
Sexually-transmitted diseases
SUBSEQUENT MANAGEMENT
l Discuss findings with the parent(s) and
child (depending on age and
understanding)
l Inform social care/police of initial
findings
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MANAGEMENT ON ADMISSION
Assessment
Management
Documentation
l Clearly document assessment in notes
with any decisions made and reasons
REFERRALS
Criteria for referral to PRT
l Deliberate self-harm (e.g. overdose,
self-strangulation, serious cuts)
l Deliberate harm from substance
misuse (e.g. poisoning from excessive
alcohol and/or illicit drugs if intention
was to self-harm)
l Mental health symptoms:
l depression/low mood with active
suicidality
l psychotic symptoms
l low weight anorexia nervosa i.e. BMI
<15 or accompanied by rapid weight
loss
l Referrals must be phoned through to
PRT before 1000 hr to be seen that day
197
GLOMERULONEPHRITIS 1/2
RECOGNITION AND
ASSESSMENT
Definition
l Acute inflammatory process affecting
the kidneys leading to haematuria,
proteinuria, oedema, hypertension and
renal insufficiency
Investigations
l Urine dipstick: large amounts of blood
and protein
l Urine microscopy: red cell casts
l U&E
l sodium may be low (dilutional effect)
l potassium, urea and creatinine
l bicarbonate may be low
l phosphate, uric acid
l albumin usually normal
l FBC: low haemoglobin (dilutional effect)
l Immunology: complement C3, ANA
and IgG, A and M
198
Differential diagnosis
l Sequelae of other bacterial/viral
infections
l Chronic renal failure with acute
exacerbation
l Henoch-Schnlein purpura
l IgA nephropathy
l Alports hereditary nephritis
IMMEDIATE TREATMENT
l Admit
l Strict fluid balance monitoring and
management
l see Renal failure guideline
l Treatment of volume
overload/hypertension
l furosemide
l see Hypertension guideline
l severe cases of fluid overload will
require dialysis
l Treatment of abnormal chemistry
consequent to renal failure
l see Renal failure guideline
l Oral antibiotics:
phenoxymethylpenicillin if able to take
tablets or amoxicillin suspension (if
penicillin allergic erythromycin) for
10 days
l Nutrition: encourage high carbohydrate
intake
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GLOMERULONEPHRITIS 2/2
SUBSEQUENT MANAGEMENT
Follow-up/progress
l Gross haematuria, oliguria and
abnormal chemistry usually resolves
by 23 weeks
l BP usually normal by 34 weeks
l Serum C3 usually normal by
46 weeks
l Proteinuria resolves by 6 months
l Microscopic haematuria resolves by
12 months
Tertiary referral
Refer to nearest paediatric renal centre if:
l Atypical presentation
l Evidence of serious degree of renal
failure requiring dialysis
l Poorly-controlled hypertension/cardiac
failure/encephalopathy
l Heavy or persistent proteinuria leading
to hypo-albuminaemia
l Normal serum C3 at presentation (i.e.
not post-streptococcal)
l Associated vasculitis
l Delay in recovery as indicated by
timescales above
l Recurrent episodes
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199
l haemolytic anaemia
l thrombocytopenia
l renal insufficiency
l Abdominal pain
l Pallor, lethargy
l Bleeding tendency
l Muco-cutaneous bleeding
l Tachycardia
l liver enlargement
Investigations
l FBC and blood film
l U&E, creatinine
l Bicarbonate
IMMEDIATE TREATMENT
l Admit, discuss with regional paediatric
nephrology team in all cases
l Strict fluid balance monitoring and
management
l See Renal failure guideline
l Dehydration
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Follow-up
l Weekly until renal function stable
DISCHARGE FROM
FOLLOW-UP
l Renal function normal
l No proteinuria
SUBSEQUENT MANAGEMENT
Tertiary referral
l If significant renal impairment (anuria,
rising creatinine) dialysis required (see
Renal failure guideline), refer to
nearest paediatric renal centre
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201
HYPERTENSION 1/4
RECOGNITION AND
ASSESSMENT
Hypertensive encephalopathy
(accelerated hypertension)
l hemiplegia
l seizure
l convulsion
Definition
l Depends on a knowledge of normal
range for age or height of child (Table 1)
l respiratory distress
l irritability
l convulsions
l Older children
l headaches
l nausea, vomiting
l tiredness, irritability
l cardiac failure
l facial palsy
l epistaxis
202
Differential diagnosis
l Incorrectly sized (too small) or placed
BP cuff
l Transient hypertension secondary to
pain, anxiety, distress
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HYPERTENSION 2/4
IMMEDIATE TREATMENT
Hypertensive encephalopathy
(accelerated hypertension)
Urgent treatment necessary but
bring BP under control slowly
Abrupt BP reduction can result in
cerebral ischaemia with the risk of
permanent neurological sequelae, owing
to failure of cerebral autoregulation after
sustained elevation of BP
l Excess BP = actual BP acceptable
BP (Table 1)
l acceptable BP given by the 90th
percentile according to height
l Reduce BP gradually. Aim to reduce
excess BP by 1/3 in first 8 hr, another 1/3
in next 12 hr, and final 1/3 in next 48 hr
l Mark target BP ranges on chart so
nurses know when to ask a doctor to
review
l Discuss choice of drug treatment with
consultant
l Options comprise in following order:
(Table 2)
l sodium nitroprusside infusion
- give in high dependency or intensive
care unit as close monitoring required
- starting dose 500 nanogram/kg/min
- increase in increments of
200 nanogram/kg/min
- maximum 8 microgram/kg/min for first
24 hr, reducing to 4 microgram/kg/min
thereafter
- only effective whilst infused as short
half-life
- stop infusion slowly over 1530 min
to avoid any rebound effects
l labetalol infusion
- do not use in heart failure
- starting dose 0.51 mg/kg/hr
- increase by 1 mg/kg/hr every 30 min
until effective
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SUBSEQUENT MANAGEMENT
Essential hypertension
l Indications for treatment are
controversial, particularly in well child
with mild hypertension (>90th
percentile) and no identifiable cause
l Treat if child has symptoms and a BP
>90th percentile, or BP consistently
well above 95th percentile (Table 1)
l start with simple measures such as
weight loss, limitation of sodium intake
and exercise
l add drug therapy only after discussion
with a consultant
Renal hypertension
l In children with impaired renal
function, keep BP within same target
range as for children with normal renal
function
203
HYPERTENSION 3/4
OUT-PATIENT MANAGEMENT
th
th
204
Girls
90th centile
Sys
Dias
100
54
102
56
103
59
104
61
106
63
107
65
108
67
110
69
111
71
112
73
113
74
114
74
116
75
118
76
119
76
122
77
124
77
126
79
127
79
130
80
132
81
95th centile
Sys
Dias
103
58
105
60
107
63
109
65
110
67
111
69
112
71
114
73
115
76
116
77
117
78
118
79
120
80
122
80
123
81
125
82
127
83
130
83
131
84
134
85
137
85
Height
(cm)
80
85
90
95
100
105
110
115
120
125
130
135
140
145
150
155
160
165
170
90th centile
Sys
Dias
101
56
102
58
102
60
103
62
104
64
106
66
107
67
108
69
109
70
111
71
112
73
114
74
115
74
117
75
119
76
120
78
121
78
122
79
124
80
95th centile
Sys
Dias
104
60
105
62
106
64
107
66
108
68
109
70
110
71
111
73
113
74
115
75
116
77
118
77
119
78
121
79
123
80
124
82
125
83
127
83
130
85
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HYPERTENSION 4/4
Table 2: Drugs commonly used for management of hypertension in children
Mechanism of action
Advice
Beta-adrenoceptor blocker l Reduces heart contractility contraindicated in early
stages of hypertensive heart failure
l Avoid in confirmed asthmatics
Labetalol Non-cardioselective beta- l Combining alpha- and beta-blockade reduces
tachycardia that can be a problem without betablocker with additional
blockade
alpha-blocking properties
l Contraindicated in asthmatics and in heart failure
l Can be used in heart failure as any negative inotropic
Nifedipine Calcium channel blocker
effect offset by a reduction in left ventricular work
l Recommended in children with renal hypertension.
Enalapril Angiotensin-converting
First dose should be given at night to prevent
enzyme (ACE) inhibitor
transient hypotension
l In children with impaired renal function, check serum
creatinine and potassium two to three days after
starting treatment and consider withdrawal if they
have risen
l Contraindicated in bilateral renal artery stenosis
l Second line if enalapril contraindicated or not
Losartan Angiotensin II receptor
tolerated
blocker
l In children with impaired renal function, check serum
creatinine and potassium two to three days after
starting treatment and consider withdrawal if they
have risen
l Contraindicated in bilateral renal artery stenosis
Drug
Atenolol
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205
Cardiovascular: difficult to
assess due to oedema
Assess for hypovolaemia carefully
l Child with diarrhoea and vomiting and
looks unwell
l Abdominal pain: strongly suggestive
l Poor peripheral perfusion and capillary
refill >2 sec
l Pulse character: thready, low volume,
difficult to palpate
l Tachycardia or upward trend in pulse
rate
l Hypotension: a late sign
l Jugular venous pressure (JVP) low
Abdomen
l Swelling and shifting dullness: suggest
ascites
206
Investigations
Femoral blood sampling is
contraindicated because of risk
of thrombosis
Urine
l Urinalysis
l Early morning urine protein/creatinine
ratio first morning after admission
l normal value <20 mg/mmol; nephrotic
>200 mg/mmol and more usually
>600 mg/mmol
Baseline bloods
l
l
l
l
l
l
l
Second-line tests
Request only if features suggestive of
more aggressive nephritis (hypertension,
macroscopic haematuria, high creatinine,
no response to corticosteroids)
l Anti-streptolysin O titre
l Antinuclear antibodies
l Anti-ds DNA antibodies
Interpretation
l High haematocrit suggests
hypovolaemia
l Raised creatinine or urea suggests
hypovolaemia, tubular plugging or
other nephritis
l Serum cholesterol and triglycerides:
often elevated
l IgG usually low
l C3 normal
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IMMEDIATE TREATMENT
General
l Admit
l Strict fluid balance monitoring
l daily weight: mandatory
l Avoid added salt, but a low salt diet
not indicated
l Manage hypovolaemia see
Complications
l seek senior advice before volume
resuscitation, as a risk of volume
overload
Fluid restriction
l Restrict to usual maintenance intake
(insensible losses plus output)
l If not tolerated, aim for:
l 600 mL/day in children aged <5 yr
l 800 mL/day in children aged 510 yr
l 1000 mL/day in children aged >10 yr
Medication
l Prednisolone 60 mg/m2 orally once
daily (maximum 80 mg), in the
morning (see BNFc for surface area)
l Phenoxymethylpenicillin (Penicillin V)
for pneumococcal prophylaxis
l If oedema upsetting to patient or
causing breathlessness, add
furosemide 12 mg/kg orally or IV
l may intensify hypovolaemia, in which
case also use 20% albumin: discuss
with consultant
l If disease severe, especially with
hypovolaemia, as judged by poor
perfusion, high haemoglobin (Hb),
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COMPLICATIONS
Acute hypovolaemia
l Abdominal pain, looks unwell,
tachycardia, poor perfusion, high Hb
l Seek senior advice before volume
resuscitation, as a risk of volume
overload
l give human albumin 4.5% (if available)
10 mL/kg immediately or sodium
chloride 0.9% 10 mL/kg immediately
l Start dipyridamole
Chronic hypovolaemia
l More common in corticosteroidresistant disease
l Looks unwell, abdominal pain and
vomiting
l Low JVP, rising urea and creatinine,
and poor response to diuretics
l Treatment: check with consultant first
l salt-poor hyperosmolar albumin 20%
0.51.0 g/kg (2.55.0 mL/kg) over
24 hr with furosemide 12 mg/kg IV
midway through infusion
l regular observations for signs of
circulatory overload (e.g. raised JVP,
tachycardia, gallop rhythm,
breathlessness)
l often required daily or twice daily:
liaise with a specialist centre
l Start dipyridamole
Peritonitis
l Difficult to recognise
l steroids may mask signs, including
fever, or cause leucocytosis
207
Thrombosis
l Renal vein: an important differential in
abdominal pain
l Cerebral vasculature
l Pulmonary vein
l Femoral vein: femoral blood sampling
contraindicated
l A fall in platelets, rise in D-Dimers and
reduced PTT are suggestive
l USS with Doppler study to look at
perfusion and to image renal vein and
IVC can be helpful. If in any doubt,
seek advice from nephrologist
regarding investigation/management
New patients
l Prednisolone 60 mg/m2 (maximum
80 mg) once daily for 6 weeks
l Then 40 mg/m2 (maximum 60 mg)
alternate days for 6 weeks
l gradually reduce dose
l Response usually apparent in 710 days
l No response after four weeks
suggests corticosteroid resistance
208
Relapsing patients
l Relapse
l three consecutive days of 3+ or more
early morning proteinuria, having
previously been in remission
l Start prednisolone 60 mg/m2
(maximum 80 mg) once daily
l continue until nil or trace proteinuria for
three days
l then 40 mg/m2 (maximum 60 mg)
alternate days for a further four weeks
l If relapses frequent despite alternateday corticosteroids for a month
l try short courses of high dose
corticosteroids
l discuss with a paediatric nephrologist
Oral prednisolone
l While on prednisolone 60 mg/m2 once
daily advise to:
l carry a corticosteroid card
l seek prompt medical attention for
illness, especially zoster contacts
Other management
l Urine testing
l teach technique and provide
appropriate dipsticks
l test only first daily urine sample
l keep a proteinuria diary
l Corticosteroid diary with instructions
regarding corticosteroid dosage
Infectious precautions
l Avoid live immunisations for 3 months
after period of treatment with highdose corticosteroids
l Benefit of inactivated vaccines can be
impaired by high-dose corticosteroids
and so a similar delay advisable where
possible
l where not possible because of
frequent relapse, give INACTIVATED
vaccines after a shorter delay and
check for an antibody response
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209
Initial investigations
l Renal ultrasound scan
l Plain abdominal film
l Urine microscopy and culture
Further investigations
l DMSA scan
l to determine function when calculi
multiple or large
l Repeat renal ultrasound scan
l to see if stones have been passed
l to monitor progress of stones
l six weeks after treatment (see below)
IMMEDIATE TREATMENT
l Analgesia for severe pain
l If obstruction is present, urgent referral
to urology at Renal Specialist centre
l Cefalexin orally if symptomatic for
urinary tract infection, adjusted once
sensitivities available
l antibiotic treatment unlikely to
eradicate organism in presence of
stones
210
OUT-PATIENT MANAGEMENT
Investigations in patients with
proven renal calculi
l Fasting (before breakfast) blood
sample for:
l creatinine
l calcium
l phosphate
l alkaline phosphatase
l uric acid
l magnesium
l venous bicarbonate
l pH (warm arterialised capillary sample
to coincide with urine pH)
l Random mid-stream urine
l microscopy, culture and sensitivity
l Early morning urine (first voided
specimen) and 24 hr collection
(request urinary stone screen and
record height and weight on request
form) for:
l sodium
l potassium
l urea
l calcium
l magnesium
l oxalate
l phosphate
l citrate
l uric acid
l cystine
l creatinine
l pH (to coincide with blood pH)
Stone analysis
l May give useful information about
aetiology, discuss with biochemistry
department first
l If stone passage is frequent or
associated with symptoms, ask
parents to strain urine
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Cystine
Uric acid
Appearance
Causes
Radioopaque*
No
Pale-yellow, crystalline
Maple syrup
Hard, yellow
Cystinuria
Yes
Lesch-Nyhan syndrome
Dietary
Induction in haematological
malignancies
Xanthinuria
No
Adenine phosphoribosyl
transferase deficiency
No
Smooth, soft,
brown yellow
Dihydroxyadenine Friable, grey-blue
Xanthine
Yes
Yes
No
* Radiolucency depends on amount of calcium in the stone and individual patient can
have more than one type of stone, each with different radiolucencies
Interpretation of results
l Urinary pH
l pH <5.3 in presence of normal
capillary pH and bicarbonate excludes
distal renal tubular acidosis
l when above criteria not met, a more
formal test of renal acidification
required in those with nephrocalcinosis
or in recurrent stone formers
l pH >6 with capillary bicarbonate
<18 mmol/L is seen in mild distal
tubular acidosis
l Calcium:creatinine (mmol/mmol) ratio
consistently >0.7 indicates
hypercalciuria
l Oxalate:creatinine (mmol/mmol) ratio
is age-dependent, and suggestive of
hyperoxaluria if it exceeds following
thresholds:
l aged <6 months: 0.35
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TREATMENT
l Treat any metabolic disorder identified
by above investigations, seek advice
from Regional Nephrology Service
l Keep urine free from infection,
particularly in those with history of
Proteus infection by prompt treatment
if symptomatic
l Advise liberal fluid intake
l adolescent 3 L/day
l pre-puberty 1.5 L/day
l Additional measures for recurrent
stone formation or idiopathic
hypercalciuria (in order):
l dietary assessment to optimise
oxalate, vitamin C, calcium, and
vitamin D intake
l reduced sodium intake in idiopathic
hypercalciuria, if sodium excretion
>3 mmol/kg/day
l high fibre diet with cellulose or whole
wheat flour to reduce calcium and
oxalate absorption
l potassium citrate in patients with low
urinary citrate
l bendroflumethiazide to reduce calcium
and oxalate excretion (unlicensed)
l For large stones that are unlikely to
pass, surgical removal or lithotripsy
may be required
l modality of treatment determined by
location and size of stone
l generally, stones <2 cm suitable for
lithotripsy
l larger stones treated by percutaneous
nephrolithotomy (PCNL) or by open
operation
l nephrectomy may be advised where
kidney function poor
212
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Presentation
l Poor/absent urine output (oliguria) with
puffiness/oedema:
l neonates <0.6 mL/kg/hr
l infant/child <0.5 mL/kg/hr
Differential diagnosis
Pre-renal
l Secondary to hypotension (e.g.
hypovolaemia from gastroenteritis or
septicaemia)
l Urine osmolality >300 mOsm/kg
l Urine:plasma urea ratio >5
l Urine sodium <20 mmol/L
l Good response to diuretics after
correction of hypovolaemia
Renal
l Haemolytic uraemic syndrome see
Haemolytic uraemic syndrome
guideline
l Acute nephritis see
Glomerulonephritis guideline
l Acute tubular necrosis or renal vein
thrombosis
l Unrecognised chronic renal failure
(oliguria usually not a feature)
l Acute-on-chronic renal failure (e.g.
dehydration or infection)
Post-renal
l Urinary tract obstruction (rare)
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Assessment
l
l
l
l
l
l
l
Hydration (under/over)
Weight
Skin (turgor/oedema)
Ascites
BP/capillary refill
Jugular venous pressure (JVP)
Urine output
Immediate investigations
l See separate guidelines for specific
causes
l Blood
l U&E, creatinine, calcium, phosphate,
uric acid, magnesium, LFTs and
bicarbonate
l FBC
l venous blood gas
l Urine
l urinalysis for blood, protein, nitrites
and leucocytes
l osmolality
l electrolytes
l Renal ultrasound scan
l size and appearance of kidneys
l inflammation and swelling
l evidence of obstruction
IMMEDIATE TREATMENT
l Correct volume status and maintain
fluid and electrolyte balance
l Prevent hyperkalaemia
l Treat underlying cause where
appropriate
l Maintain adequate nutrition
213
l Volume overload/hypertension
l low serum sodium usually indicates
fluid overload
l furosemide 1 mg/kg IV immediately
(max rate: 500 microgram/kg/min up to
4 mg/min): if no urine output after
30 min, give a further 1 mg/kg and if still
no urine a third 1 mg/kg after 30 min
Metabolic acidosis
l Sodium bicarbonate may be required
discuss with consultant on-call
Potassium
l Hyperkalaemia can lead to cardiac
arrest or serious arrhythmias
l severely restrict potassium intake by
introducing low potassium diet and
avoiding potassium in IV fluids unless
serum potassium <3.5 mmol/L or there
are ongoing losses
l If potassium >6.0 mmol/L, ECG
monitoring essential
Dose
2.55 mg as single dose
Onset
5 min
Immediate. Effect
maximal at 60 min
5 min
Polystyrene
sulphonate
resins
214
Calcium resonium
250 mg/kg 6 hrly (max
15 g/dose) orally/rectally
Mode of action
Shifts potassium into
cells
Shifts potassium into
cells
Antagonises effect of
high potassium
Removes potassium
from body
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SUBSEQUENT MANAGEMENT
Fluid and sodium balance
l Once normal hydration restored, aim
to replace insensible loss
(300400 mL/m2/day) + urine output
+ other losses
l In anuric patients (as opposed to
oliguric), give fluids that are free of
electrolytes to compensate for
insensible loss; in patients having IV
fluids, glucose 5% is most appropriate
initially, although glucose 4%/sodium
chloride 0.18% may be required later
to compensate for sodium loss from
sweat
l Replace sodium losses in urine and in
other fluids (diarrhoea, gastric aspirate,
fistula)
l in most patients, dietary sodium will
suffice
l in those with large fluid losses,
consider IV sodium to match losses
MONITORING TREATMENT
l Accurate fluid balance maintain strict
input-output chart
l Re-assess fluid intake at least 12 hrly
l Record weights, plasma sodium and
PCV as indicators of hydration
l Check K+ hourly if >6 or <3 mmol/L
l Check U&E 12 hrly if K+ 36 mmol/L in
renal failure
l Respond promptly to increase in urine
volume, fall in serum creatinine and
increase in urine osmolality by
increasing fluid intake to prevent
prolonged oliguria
l Once diuresis begins, increase
electrolyte replacement, including
potassium
l once stable, reduce fluid intake
gradually to avoid prolonged diuretic
phase
Nutrition
l Involve a paediatric dietitian
l A low-protein high-energy diet is ideal
(aim for energy intake of 400 kcal/m2)
l Avoid high potassium foods
l Be realistic about what a child will take
215
Protein:creatinine ratio
l Best performed on first urine specimen
voided in the morning
l Upper limit of normal <20 mg/mmol
l Significant proteinuria >100 mg/mmol
l Heavy proteinuria (nephrotic)
>200 mg/mmol
Timed collection
l Only appropriate for older patients (out
of nappies)
l Night-time collection to rule out
orthostatic proteinuria
l empty bladder at bedtime and discard
sample
l collect all specimens passed during
the night
l empty bladder on rising in morning
and collect sample
l record time from bladder emptying at
night to bladder emptying in morning
l Calculate protein output as mg/m2/hr
(see BNFc for surface area)
l Upper limit of normal = 2.5 mg/m2/hr
l Heavy proteinuria >40 mg/m2/hr
216
Tubular proteinuria
l Request retinol binding protein
(RBP):creatinine ratio elevation
confirms tubular proteinuria
OSMOLALITY
l Used to exclude urinary concentrating
disorders
l patients with polyuria (may present as
wetting or excessive drinking)
l Test early morning urine after
overnight fast >870 mOsm/kg virtually
excludes a concentrating defect
l if concern re diabetes insipidus, do
water deprivation tests during the day
SODIUM EXCRETION
l Fractional sodium excretion (FENa)
assesses capacity to retain sodium
l ensure normal sodium intake (dietitian
to advise)
l stop any existing supplements 6 hr
before taking samples
l document weight loss after
supplements stopped, may provide
useful supporting evidence
l random urine sample for urinary
sodium (UNa) and creatinine (UCr)
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Height (cm)
Mean (mol/L)
66
44
34
28
33
38
42
46
52
68
86
50
60
87
101
114
126
137
147
163
174
Upper limit
87
58
49
39
43
52
57
62
69
89
108
Mean GFR
(mL/min/1.73 m2)
48
Up to 1 month
77
16 months
103
612 months
127
12 yr
127
212 yr
Range (2 SD)
2868
41103
49157
63191
89165
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51
217
Length (mm)
45
Range (mm)
3560
50
55
58
65
75
80
86
5060
5260
5464
5472
6488
7386
73100
ISOTOPE SCANS
Dynamic imaging (MAG3)
Indications
Operational notes
218
Operational notes
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>3 months
pre-verbal
Older verbal
Most common
Fever
Vomiting
Lethargy
Irritability
Fever
Intermediate
Poor feeding
Failure to thrive
Frequency
Dysuria
Dysfunctional voiding
Changes to continence
Abdominal pain
Loin tenderness
Abdominal pain
Loin tenderness
Vomiting
Poor feeding
Investigations
l Dipstick test fresh urine for leukocytes
and nitrites in:
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Least common
Abdominal pain
Jaundice
Haematuria
Offensive urine
Lethargy
Irritability
Haematuria
Offensive urine
Failure to thrive
Fever
Malaise
Vomiting
Haematuria
Offensive urine
Cloudy urine
Collection of specimens
Do not delay treatment if a sample
cannot be obtained and child at high risk
of serious illness
l Clean catch in sterile container is
recommended method:
l in babies too young to co-operate
eliciting lateral abdominal reflex may
provoke micturition
l Collect mid-stream urine in those old
enough to co-operate
219
Handling specimens
220
Interpretation of results
Always take clinical symptoms into
account when interpreting results
Stick testing (NICE recommend only
in children >3 yr)
l Negative for leukocytes and nitrites
excludes urinary tract infection
l Positive for leukocytes and nitrites gives
high probability of infection
l Positive for either leukocytes (more than
1+) or nitrites requires culture or
microscopy if no other focus of infection
IMMEDIATE TREATMENT
If child systemically unwell, do not delay
treatment while trying to obtain urine
specimen
l Ensure good hydration with
maintenance fluids
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SUBSEQUENT MANAGEMENT
Imaging
Dependent of age and type of infection
l Simple UTI: responds within 48 hr
l Atypical UTI: where initial symptoms
suggest upper tract infection or there
are other symptoms such as voiding
difficulty, not responding within 48 hr
l Recurrent UTI: 2 episodes of UTI with
systemic upset, 1 systemic and
1 simple, 3 simple UTIs
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Test
Simple UTI UTI +
Aged 06 months
US
Yes
Yes
DMSA No
Yes
MCUG No
Yes
Aged 6 month to 3 yr
US
No
Yes
DMSA No
Yes
MCUG No
No
Aged >3 yr
US
No
Yes
DMSA No
No
No
MCUG No
Recurrent UTI
Yes
Yes
Yes
Yes
Yes
No
Yes
Yes
No
l Home when:
l symptoms mild, or severe symptoms
controlled
l taking oral antibiotics and tolerating them
l renal function normal or returning to
previous values in those with impaired
function
l discuss and advise to avoid risk factors
at discharge:
- constipation
- poor hygiene
- low fluid intake
- infrequent bladder emptying
l Repeat urine test not required on
asymptomatic children
l Prompt treatment of recurrences with
co-amoxiclav
l Out-patient review
l not required for simple UTI
l in 810 weeks where ultrasound
imaging has been indicated
221
222
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Expires: November 2012
ARTHRITIS 1/1
RECOGNITION AND
ASSESSMENT
Definition
l Acute, chronic or recurrent
inflammation of a one or more joints
Differential diagnosis
l Juvenile idiopathic arthritis (JIA): arthritis
of unknown aetiology before age 16 yr
persisting for 6 weeks or more
l Reactive arthritis (self-limiting in
response to an infection)
l Non-accidental injury
l Systemic rheumatic diseases, such as
SLE, dermatomyositis, vasculitis
(including HSP and Kawasaki disease)
l Arthritis associated with inflammatory
bowel disease
l Malignancy, especially leukaemia or
neuroblastoma
l Rickets and other endocrine disease
(e.g. type 1 DM, thyroid disease)
l Infectious causes (e.g. TB, rheumatic
fever, Lyme disease)
Rarer causes
INVESTIGATIONS
l X-rays of joints most affected if child
has features of other differential
diagnoses that have radiological
Issue 4
Issued: November 2010
Expires: November 2012
ACUTE MANAGEMENT
l Telephone local paediatric
rheumatology team for advice for
management of musculoskeletal
conditions and assessment of pyrexia
of unknown origin
l Analgesia/anti-inflammatory
medication in order of increasing risk
of side effects but also clinical
effectiveness:
l ibuprofen naproxen piroxicam (see
BNFc for dose based on weight)
223
Common/important diagnoses
l
l
l
l
l
l
l
l
l
l
l
l
l
Any age
Aged 0-4 yr
Aged 4-10 yr
Aged 11-16 yr
HISTORY
Musculoskeletal
Ask about:
Check:
l Fever: shivering/sweating
l Joint swelling
l Trauma
l Delayed presentation
EXAMINATION
General
Look for:
l Fever
l Rash
l Pallor
l Bruising
l Impaired growth
l Gait
l Range of movement
l Leg lengths
l Weakness
l Spinal configuration/movement
INITIAL INVESTIGATIONS
l FBC and film
l ESR
l CRP
224
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l effusion on USS
OR
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225
l CRP
Any abnormality?
l Abnormal X-ray
l Severe pain
l Local tenderness
l Effusion on USS
YES
NO
Discharge home with
analgesia
WORSE
Review at 5 days
Normal
DISCHARGE
Orthopaedic opinion
(withholding
antimicrobials)
Review at 10 days
Abnormal
Normal
Joint
orthopaedic/paediatric
review
Consider paediatric
rheumatology referral
226
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Expires: November 2012
INDEX 1/3
A
Abdominal pain
Abuse
110
19, 190-193, 194-196, 197
Adrenaline
Alcohol poisoning
78
ALTE
18
Amiodarone
Anaesthesia
2728, 36,75,187,188
Analgesia
Coarctation
62, 65
Codeine
22, 24
45
62
Cystic fibrosis
141
Antipyretics
112
Croup
20
Antibiotics
62
Constipation
23
Anaphylaxis
189
Coma scale
149
Admission
47
53
Exacerbation
49
Microbiology
51
APLS
Cardio-respiratory arrest
12
223
Arthritis septic
168
Arthritis JIA
223
38
Asystole
9, 10
AVPU
14, 15
B
Bacterial infection
Bites
Blood pressure
142
12, 180, 202
130
70, 71
42
D
Dental endocarditis prophylaxis
75
90
99
Diabetic ketoacidosis
116
Diclofenac
Dietitian referral
24, 135
47, 100, 122
53
DKA
93
62
E
ECG interpretation
EEG
66
181, 182, 183
Effusion
5759
93
Encopresis
Calculi renal
210
Cardiac arrest
Epiglottitis
45
64
Epilepsy
185
Epilepticus, status
186
Cardiogenic shock
Cardiopulmonary resuscitation (CPR)
Cellulitis orbital
Cervical lymphadenopathy
Chickenpox
Child protection
Child sexual abuse
Issue 4
Issued: November 2010
Expires: November 2012
10, 11
Endocarditis prophylaxis
75
167
143
51, 52
190
194
F
Facial palsy
180
Faecal impaction
Failure to thrive
125
227
INDEX 2/3
Fallots tetralogy
Iron poisoning
79
90
IV fluid therapy
32
Fasting pre-operatively
36
Febrile neutropenia
131
Fever
147
Fits
161, 186
Fluid therapy
32
29
Food poisoning
165
G
General anaesthesia (GA)
37
189
Glomerulonephritis
198
J
127
Jaundice
Juvenile idiopathic arthritis (JIA)
223, 224
K
Kawasaki disease
157
Ketone monitoring
107
L
Limping child
224
33
Lumbar puncture
H
Haematuria
Lymphadenopathy
143146, 178
200
Haemophilia
138
64
Henoch-Schnlein purpura
134
Hepatitis
150
149
151
153
Hyperkalaemia
66, 214
Hypernatraemic dehydration
118, 119
M
Malaria
159
Malignant hyperthermia
187, 188
Meningitis
161
Meningococcal septicaemia
Morphine
2426, 28
N
Nephrotic syndrome
206
Neuromuscular disorders
187
Hypertension
202
Neutropenia, febrile
Hypoglycaemia
101
Nocturnal hypoventilation
187
190
165
122
Hyponatraemia
I
Ibuprofen
131133
24
Idiopathic thrombocytopenic
purpura (ITP)
136
Imaging renal
218
Oncology
130
Immunodeficiency
155
Orbital cellulitis
167
Insulin
Intraosseous infusion
Intravenous (IV) lines, flushing
Ipratropium bromide
228
16
168
29
39, 41
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Expires: November 2012
INDEX 3/3
Stones - renal
P
Pain assessment
22
Paracetamol
22, 23, 81
Paracetamol poisoning
90, 92
81
25
173
85
33, 34
T
Tachycardia and bradycardia
136
Transfusion
130
108
Tricyclic poisoning
Platelet transfusion
130
Tuberculosis
Pleural effusion
57
Pneumonia
54
Pneumothorax
60
76
Post GA monitoring
ex-premature infants
37
36
Varicella (VZV)
Pre-op fasting
Pulseless electrical activity (PEA)
9, 10
70
Purpura
210, 212
88
177
U
Urinary tract infection (UTI)
219
R
Rash
173
Renal calculi
210
Renal failure
213
Renal investigations
216
42, 45
Resuscitation
10, 11
S
Salbutamol
Salicylate poisoning
Sedation
Seizure
Self harm
168172, 224
Sexual abuse
194
Shock IO access
174
Sinusitis
167
Speech arrest
182
Status epilepticus
186
Steroid dependence
180
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229
NOTES
230
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NOTES
232
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NOTES
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NOTES
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Issue 4
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Expires: November 2012
ISBN 978-0-9567736-0-9
ISSUE 4
Printed by: Sherwin Rivers Ltd, Waterloo Road, Stoke on Trent ST6 3HR
Tel: 01782 212024 Fax: 01782 214661 Email: sales@sherwin-rivers.co.uk